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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.
Drug use/ utilization evaluation and medication utilization evaluations are the same as drug utilization review. [ 3 ] With the development of society and the economy, the costs of health care grows rapidly, and this becomes a burden on the worldwide health protection system. [ 4 ]
Clinical peer review, also known as medical peer review is the process by which health care professionals, including those in nursing and pharmacy, evaluate each other's clinical performance. [1] [2] A discipline-specific process may be referenced accordingly (e.g., physician peer review, nursing peer review).
These physicians are contracted by an independent review organization, medical management companies, third party administrators (TPAs) or utilization review companies to provide objective, unbiased determinations on what the root cause of the treatment was, whether there is medical necessity, if there was a sentinel event, what was the reason ...
Image source: The Motley Fool. HCA Healthcare (NYSE: HCA) Q4 2024 Earnings Call Jan 24, 2025, 10:00 a.m. ET. Contents: Prepared Remarks. Questions and Answers. Call ...
Persuasive utilization is the enlistment of evaluation results in an effort to persuade an audience to either support an agenda or to oppose it. Unless the 'persuader' is the same person that ran the evaluation, this form of utilization is not of much interest to evaluators as they often cannot foresee possible future efforts of persuasion. [8]
An independent reviewer is an individual who does not have direct professional responsibility for the design stage under review, assuring an independent and objective review. Within the context of formal design reviews, the practical solution is simply to ensure a fresh perspective, based on the principle that those who are too close to the ...
This field deals with utilization of machine-learning algorithms and artificial intelligence, to emulate human cognition in the analysis, interpretation, and comprehension of complicated medical and healthcare data. Specifically, AI is the ability of computer algorithms to approximate conclusions based solely on input data.
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