Utilization Management- Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards. Utilization Review- A mechanism used by some insurers and employers to evaluate healthcare on the basis of appropriateness, necessity, and quality.
What is the Medicare provider utilization and payment data file?
These Medicare Provider Utilization and Payment Data files include information for common inpatient and outpatient services, all physician and other supplier procedures and services, and all Part D prescriptions.
What is utilization management in health care?
In this report, the committee considers utilization managementas 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.
What is the outpatient utilization and payment public use file?
The Outpatient Utilization and Payment Public Use File (Outpatient PUF) presents information on common outpatient services provided to Medicare fee-for-service beneficiaries. To navigate directly to the Outpatient PUF, please use the links below.
What is Aetna’s utilization review policy for outpatient infusion?
In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors. Aetna’s site of care policy provides the criteria we use to determine the medical necessity of hospital outpatient infusion. Note: More stringent state requirements may supersede the requirements of this policy.
What is Medicare utilization?
These Medicare Provider Utilization and Payment Data files include information for common inpatient and outpatient services, all physician and other supplier procedures and services, and all Part D prescriptions.
What is insurance utilization?
Utilization review (UR) is the process of reviewing an episode of care. The review confirms that the insurance company will provide appropriate financial coverage for medical services. The UR process and the UR nurse facilitate minimizing costs.
What does utilization mean in medical terms?
(ūt″ĭl-ĭ-zā′shŏn) [L. utilis, usable] In health care, the consumption of services or supplies, such as the number of office visits a person makes per year with a health care provider, the number of prescription drugs taken, or the number of days a person is hospitalized.
What does hospital utilization mean?
The usage rate of a particular health care facility; a group of statistics referring to a population's use of hospital services.
What is patient utilization?
Utilization management (UM) is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis.
What are the three types of utilization review?
Utilization review contains three types of assessments: prospective, concurrent, and retrospective.
How is utilization calculated?
The basic formula is pretty simple: it's the number of billable hours divided by the total number of available hours (x 100). So, if an employee billed for 32 hours from a 40-hour week, they would have a utilization rate of 80%.
How is healthcare utilization measured?
Measure of services utilization, from the physician's perspective, is often based on economic indicators based on volume, such as number of hospitalizations per year, number of medical acts, number of patients and number of visits (Andersen and Newman 1973; Beland 1988).
Why is utilization important in healthcare?
1. Utilization management can prevent unnecessary costs. Utilization management can help reduce the rising rates of healthcare costs—and in the current situation, that's more important than ever. Healthcare costs typically rise each year.
What is the purpose of the insurance claim utilization review process?
What is the purpose of the insurance claim utilization review process? Returned claims can be corrected and refiled. Denied insurance claims can be corrected and re-filed.
What are utilization costs?
Health care utilization cost is the total amount paid by an insurance plan for the insured parties' health services. Health care utilization costs are one measure used to determine the cost of an employer sponsored health insurance plan.
What is the utilization report for health insurance?
This report allows you to identify and educate your employees on how to help contain costs with the proper usage of health plan benefits.
How does utilization management work?
There are some aspects of utilization management that are specific to prescribing drugs and tracking their effects. For example, many drugs require prior authorization before they can be dispensed. This authorization step allows the insurer to verify if there are lower-cost or generic options available, and also reduces the chance of addiction and abuse. Quantity limits also prevent waste and reduce the potential for abuse and addiction. Patients can also ask for exceptions and medicines, but these must be approved by the insurer before they will be covered. Insurers can also track patient adherence to a treatment plan by refill rates.
What specialties do you need to include in utilization management?
In addition to primary care, pharmacy, advanced care, emergency services, behavioral health, psychiatry and substance abuse, and surgery, you’ll need to include any other relevant specialties. Run utilization management daily, on all cases, and document all key steps in order to provide the best data.
What does URAC stand for?
URAC (which originally stood for Utilization Review Accreditation Commission, but now has no official meaning) is a non-profit organization that runs accreditation programs for many areas of healthcare (they also provide education programs). One of their areas of accreditation is utilization management.
What is UR in medical terms?
Utilization review (UR) is a process in which patient records are reviewed for accuracy and completion of treatment, after the treatment is complete. UR, a separate activity, can be a part of UM (specifically during retrospective review), and can drive changes to the UM process.
What percentage of medical expenses are covered by high cost cases?
It’s estimated that one to seven percent of patients can account for 30-60 percent of costs. Utilization management case managers focus mainly on reducing costs over other key goals.
What is UM in healthcare?
Utilization management (UM) is a complex process that works to improve healthcare quality, reduce costs, and improve the overall health of the population . This guide explains how it works, who it helps, and why it’s important.
What are the three types of UM reviews?
UM has three main types of reviews: prospective, concurrent, and retrospective. This structure is comparable to the Donabedian model of healthcare quality, developed in the late 20th century by Avedis Donabedian. Each kind of review can impact the process differently.
CCMC Key Definitions Related to Utilization Management
Utilization Management- Review of services to ensure that they are medically necessary, provided in the most appropriate care setting, and at or above quality standards.
Utilization Management vs. Utilization Review
The terms utilization review and utilization management are often used interchangeably. It is true that the evaluation process for utilization review and utilization management is similar or the same and both assess medical care for appropriateness. It is also true that the goal for both is to control the cost of healthcare services.
The Utilization Management Process
Verify eligibility- Check that the patient is covered under the health plan, and that this coverage is primary. Example: The patient may have Medicare and insurance through his employer. The primary insurance is the one the preauthorization request would go through.
What is utilization management?
Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review.”
What is population health?
Population Health: the health outcomes of groups of individuals including distribution of such outcomes…. aims to improve health of entire population. A priority considered important in achieving this aim is to reduce health inequities or disparities among different population groups due to, among other factors, the social determinants of health (SDOH)
Outside vendors
In some states, we delegate utilization review of certain services, including radiology and physical/occupational therapy, to vendors.
Drug infusion site of care policy
The Aetna site of care policy provides the criteria we use to determine the medical necessity of hospital outpatient infusion.
Outpatient surgery site of service policy
Using cost-effective sites of service for certain outpatient surgical procedures can help members save.
Radiology imaging site of care policy
Imaging procedures will be reviewed for medical necessity before being approved in an outpatient hospital setting.
Legal notices
Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).
