Utilization Management Flashcards

What is the primary purpose of utilization management in case management?

Answer: To ensure appropriate use of healthcare resources while maintaining quality

Utilization management ensures healthcare resources are used appropriately and efficiently while maintaining quality patient care outcomes.

Which type of utilization review involves evaluating the appropriateness of care BEFORE it is provided?

Answer: Prospective review (prior authorization)

Prospective review, also called prior authorization, occurs before care is delivered to determine medical necessity and appropriateness.

InterQual and Milliman Care Guidelines are examples of:

Answer: Evidence-based clinical criteria used in utilization review

InterQual and Milliman Care Guidelines are evidence-based clinical criteria tools used to assess medical necessity and appropriate level of care.

When a payer denies a claim for lack of medical necessity, the case manager's FIRST step should be to:

Answer: Review the denial reason and gather supporting clinical documentation

The first step after a denial is to review the reason and gather clinical documentation to support an appeal if appropriate.

Concurrent utilization review is performed:

Answer: During the course of treatment or hospitalization

Concurrent review occurs during an ongoing episode of care to assess continued medical necessity and appropriateness of the current level of care.

Which organization accredits utilization review organizations (UROs) and sets standards for utilization management programs?

Answer: URAC (Utilization Review Accreditation Commission)

URAC accredits utilization review organizations and establishes national standards for utilization management programs.

A 'peer-to-peer review' in utilization management involves:

Answer: A treating physician speaking directly with a medical reviewer to discuss a denial

A peer-to-peer review allows the treating physician to discuss a utilization denial directly with the payer's medical reviewer to provide additional clinical context.