Question

Perform a web-search and locate information about utilization review in healthcare. What is utilization review? How does it relate to Health Information Management? How does it relate to coding? What are skill needed to perform utilization review?250 words

Answer 1

Utilization review examines how health care services are being utilized. This includes examining which services are being used by patients; how long the services are lasting; whether or not the services are effective; and how much money it costs to provide the services.

Case management is a broad category that fits within the larger field of human services. Generally, case management involves coordination of care, advocacy and discharge planning; however, counseling and therapeutic support may also be offered. Case management aims to assist the individual to navigate social service systems and attain the highest quality of care.

What is the difference?

Utilization Review - examines how services are being utilized, whether or not the services are effective and how much money it costs to provide the services

Case Management – coordinates care and assists the patient to navigate social service systems to attain the highest quality of care

Whose Role is UR?

In most hospitals both positions are handled by the Case Management Department making it difficult to differentiate between two completely different tasks.

Utilization is the task of every member of the organization.

Responsibilities:

Physicians – Appropriate orders for admission and effective treatment.

Ancillary Services (PT/OT, Radiology, Lab) - Makes sure orders are carried timely and effectively. Dietary – Provide nutrition needed to accomplish the treatment required.

Administration – Provide an environment conducive to efficient, therapeutic and cost contained treatment.

Who has the biggest role?

NURSING:-

Most Case Management departments are staffed with nurses.

Staff nurses have the biggest influence in how effective a patient’s treatment plan is followed and have the responsibility to follow up if the plan is ineffective.

How can the nurse help?

1. Know your patient.

2. Know the plan of care.

3. Monitor the effectiveness.

4. Be both the patient and the Hospitals advocate.

5. Develop a good working relationship with the Physicians.

6. Be assertive.

Using a new network-centric utilization management model, healthcare organizations are realizing up to $20 million in total net financial savings and up to 80 percent reduction in the number of codes requiring review.

Healthcare organizations that want to increase value from utilization management—and improve provider relationships—are disrupting the status quo. They are adopting a risk-based, data-driven approach to replace the traditional disease-centric utilization management model with a networkcentric one. The new model focuses on practice patterns to drive efficiencies in receipt and review of requests and enables utilization management clinicians to work at peak productivity. It can save medical and administrative costs, reduce provider burden, and improve consumer satisfaction.