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Utilization management

Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its medical appropriateness before it is provided, by using evidence-based criteria or guidelines.

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Overview

Aspects

Integrated delivery system

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Regulation

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Utilization management

Nodes51
Edges50
Triples33
Avg. degree1.96
Density0.039216
Components1

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Utilization management

Top relations

related to Aspects · 10
Utilization management → But, Institute, IOM, Medicine, Medicine Committee, National Academy, Third Parties, Typically, UM, Utilization
related to Integrated delivery system · 5
Utilization management → As, Boeing, HMO, In, Walmart

Important terminology Word statistics

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Important terminology

care um criteria may review medical guidelines health patient denial 2019 insurance claims typically case point found utilization management healthcare

Entity relationships Subject–Predicate–Object triples

SubjectPredicateObjectConfidenceSrc
prior authorization that allow payersinstance ofor utilization review is the use of managed care techniques0.80text
particularly health insurance companiesinstance ofor utilization review is the use of managed care techniques0.80text
to manage the cost of health care benefits by assessing its medical appropriateness before it is providedinstance ofor utilization review is the use of managed care techniques0.80text
by using evidence-based criteria or guidelines.Critics have argued that if cost-cutting by insurers is the focus of their use of UM criteriainstance ofor utilization review is the use of managed care techniques0.80text
it could lead to healthcare rationing by overzealous denial of care as well as retrospective denial of paymentinstance ofor utilization review is the use of managed care techniques0.80text
delays in careinstance ofor utilization review is the use of managed care techniques0.80text
or unexpected financial risks to patientsinstance ofor utilization review is the use of managed care techniques0.80text
patient-reported outcomes or measures of appropriateness.Medicare issues national coverage determinations on specific treatments.Timing of reviewSimilar to the Donabedian healthcare quality assurance modelinstance ofFindings from a 2019 systematic review identified how guidelines for UM are often more focused on reduction of utilization than on clinically meaningful measures0.80text
UM may be done prospectivelyinstance ofFindings from a 2019 systematic review identified how guidelines for UM are often more focused on reduction of utilization than on clinically meaningful measures0.80text
retrospectivelyinstance ofFindings from a 2019 systematic review identified how guidelines for UM are often more focused on reduction of utilization than on clinically meaningful measures0.80text
or concurrently.Prospective review is typically used as a method of reducing medically unnecessary admissions or procedures by denying cases that do not meet criteriainstance ofFindings from a 2019 systematic review identified how guidelines for UM are often more focused on reduction of utilization than on clinically meaningful measures0.80text
or allocating them to more appropriate care settings before the act.Concurrent review is carried out duringinstance ofFindings from a 2019 systematic review identified how guidelines for UM are often more focused on reduction of utilization than on clinically meaningful measures0.80text

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