Utilization management

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Health care

Health care services

Health care administration Health care costs Health care delivery Health care policy Health care systems Health care utilization Health service management Health service needs

Types of services

Community services Community mental health services Health maintenance organizations Integrated services Mental health services Managed care Primary care services Primary health care Private practice

Related topics

Case management Costs and cost analysis Cost containment Fee for service Quality of care Quality of services

In health care utilization utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the needs assessment.

Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.

As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review.

While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is forward looking and intends to manage health care cases efficiently and cost effectively before and during health care administration. Utilization review is more backward looking considering whether health care was appropriately applied after it was administered.

There are four basic techniques in utilization management: Demand Management

• Utilization Review
• Case Management

Disease Management

See also

• Health care costs
• Health insurance
• Managed care
• Quality of care