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Pages:
4 pages/β‰ˆ1100 words
Sources:
4 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
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Topic:

Utilization Review and Case Management Essentials

Case Study Instructions:

With the consistently rising costs of health care services, utilization management and utilization review are routinely used in the vast majority of current health care settings. How are they evolving over time, and what is involved in these processes? What do health care managers need to be aware of as the processes play out?
In the absence of sweeping policy change (or the complete restructuring of the United States health care system), utilization management and utilization review are much more moderate processes to attempt to preserve the quality of care provided while controlling overall health care expenditures. Let’s learn a bit about each of these processes, and how they are implemented in our current health care environment.
Case Assignment
Using the information in the required readings as well as some additional research in peer
reviewed sources, complete your Case Assignment by answering the following:
Please identify each question with a subtitle, Cite the author, and use additional Peer reviews from at least 2 scholars.
1. Compare and contrast utilization review and utilization management in health care. What are the similarities and the differences between each type of assessment? (Hint: One is generally a prospective process, and the other is generally a retrospective process).
2. Explain the specific role of each method in providing value-based health care. Who benefits from the method—the health care system, the insurance company, and/or the patient?
3. Articulate how individual case management is critical to a hospital’s long-term survival. In what way does this practice protect your patients while keeping your doors open for business?
4. What are the ethical pitfalls to be aware of in performing these types of quality reviews? What must health care managers be aware of in terms of ethical pitfalls and also potential unintended negative consequences?
Assignment Expectations
1. Conduct additional research to gather sufficient information to support your analysis.
2. Provide a response of 4 pages, not including title page and references.
3. As we have multiple required items to be addressed herein, please use subheadings to show where you’re responding to each required item and to ensure that none are omitted.
4. Support your paper with peer-reviewed articles and reliable sources. Use at least three references, and a minimum of two of these from peer-reviewed sources. For additional information on how to recognize peer-reviewed journals, see:
Angelo State University Library. (n.d.). Library Guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www(dot)angelo(dot)edu/services/library/handouts/peerrev.php

Case Study Sample Content Preview:

Utilization Review and Case Management Essentials
First Name, Last Name
Institutional Affiliation
Date
Utilization Review and Case Management Essentials
The rising costs of care delivery necessitate implementing processes and practices that work in tandem to reduce costs while improving the quality of care (Giardino & Wadhwa, 2021). Often referred to as Utilization Reviews or Utilization Management, these processes benefit various entities and come with their ethical implications. This paper details the essentials of these processes, how they are significant, whom they help, their role in healthcare, and their ethical pitfalls.
UR (Utilization Review) vs UM (Utilization Management)
While UM (Utilization Management) and UR (Utilization Review) are both processes designed to reduce the cost of care while improving or maintaining healthcare quality, they differ substantially. UM is a prospective process done at the start or before treatment is delivered to ensure it is appropriate by eliminating duplicate, unnecessary or ineffective treatments. It involves analyzing the case of a patient and their proposed intervention. The health professional’s selected treatment can be overridden or changed in UM. Therefore, this process can create resentment in the health practitioner or the patient (Giardino & Wadhwa, 2021).
In contrast, UR is a retrospective process done after treatment is complete to assess a clinical intervention's appropriateness and efficacy, including the setting where care was delivered. The goal of UR is to determine the treatments that are effective so that healthcare professionals can use them for future patients. Utilization Reviews can also identify issues and successes from a clinical intervention and relay the information back to caregivers. This review does not have the potential to create resentment in the medical staff because the data collected can only identify issues in treatment or point out the successes (Kongstvedt, 2020).
Role and Benefits of UR and UM
Role in Providing Value-Based Healthcare
Value-based healthcare is an approach that ensures that the healthcare provider receives their payment based on the patient’s health outcomes. Utilization Review and Utilization Management play a vital role in providing value-based healthcare. UR helps providers reduce denials while delivering effective and quality treatment to their patients. The reviewers use the data they gather after treatment is finished to evaluate if it is effective. If the treatment is effective and a health professional prescribes it, an insurer will likely approve that treatment because it is proven to work well (Duncan, 2022). Therefore, patient health outcomes are met. Conversely, since UM is done before or at the start of treatment, a provider can discover any unnecessary, harmful, or duplicate treatments and stop them from being delivered (Giardino & Wadhwa, 2021). Therefore, financial resources will not be wasted, claims will not be denied, and the patient will receive adequate treatment to improve their health outcomes.
Benefits to Patients, Providers, and Insurers.
UM and UR realizes several benefits for the patients, the hospitals (healthcare providers), and the insurers. One a...
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