Question

Compare types of authorization systems used to control the utilization and cost of health care services. Explain one type of authorization and where it would be used.

Answer 1

Utilization Management in Health care Services

                Health Care Utilization is the quantification or description of the use of services by persons for the purpose of preventing and curing health problems, promoting maintenance of health and well-being, or obtaining information about one's health status and prognosis.

             Utilization management as a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.

Utilization of the healthcare services can be control by:

• Prior Review

Prior review provides advance evaluation of whether medical services proposed for a specific person conform to provisions of health plans that limit coverage to medically necessary care. The focus may be on the site of care, the timing or duration of care, or the need for a specific procedure or other service. To encourage patients covered by a health plan to cooperate in the prior review process, a financial penalty, such as higher cost-sharing, may apply when individuals fail to obtain necessary certifications

• High-Cost Case Management

High-cost case management—also called large case management, medical case management, catastrophic case management, or individual benefits management—focuses on the relatively few beneficiaries in any group who have generated or are likely to generate very high expenditures. Case management for individuals with high-cost illnesses is similar to other forms of social and health case management, in that it involves assessing a person's needs and personal circumstances and then planning, arranging, and coordinating the recommended services.

• Retrospective Utilization Review

Utilization management techniques, particularly prior review methods, attempt to overcome the disadvantages and unhappiness associated with retrospective review and denial of claims after services have already been provided. Retrospective claims and medical record reviews can, however, support and reinforce utilization management by

a) monitoring the accuracy of information provided during prior review and identifying problem areas,

b) examining claims that are unsuitable for predetermination (generally those with high volume and low unit costs), and

c) Analyzing patterns of practitioner or institutional care for use in provider education programs and selective contracting arrangements.

Cost Control in Health care Services

Health care costs can be controlled or decreased only by using strategies that decrease the following:

· How much people use health care services

· How much providers are reimbursed for services

· How much the overhead of running a health care business is (overhead excludes the costs of providing health care)

a. Decreasing the use of Healthcare systems

· Limiting access to care, which may prevent unnecessary care but may make getting necessary care more expensive, difficult, or impossible

· Limiting need for care, by improving health and preventing disease

· Eliminating unnecessary care

· Improving health

b. Decreasing Reimbursement of care used

· Lower fees

· Increased use of primary care

· Prospective payment systems

· Accountable Care Organizations