Improving Outcomes in Utilization Management. Module A. Dynamics
This module lays out the basics of utilization management, and how a case manager can execute that process in an ever-changing environment of healthcare. First, it looks at the basic process—the evaluation of the medical necessity, appropriateness and efficiency of the use of healthcare services, procedures and facilities as a means of approving medical coverage. It highlights the process of UM in part by looking at the system it replaced, utilization review, which looks backward in a sense, evaluating how effective services were before approving coverage. UM, on the other hand, looks forward; the module then explores how the team working along the continuum of care can help determine the best care for the patient, a factor needed to ensure payment for the hospital.