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Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
The Andersen healthcare utilization model is a conceptual model aimed at demonstrating the factors that lead to the use of health services. According to the model, the usage of health services (including inpatient care, physician visits, dental care etc.) is determined by three dynamics: predisposing factors, enabling factors, and need.
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
For example, some Medicare Advantage plans have $0 premiums and can help pay all or part of your Part B premium ($185 a month in 2025 Upper-income Medicare beneficiaries, however, pay a surcharge ...
HCUP Logo. The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ).
Utilization behaviour is when a patient automatically uses an object in the appropriate manner, but at an inappropriate time. [7] For example, if a pen and paper are placed in front of an individual with DES they will start to write or if there is a deck of cards they will deal them out.
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 ...
One example of the impact of better care coordination is our emergency room space discharge program, which helps patients who may be at risk for unnecessary and expensive ER use and readmissions.
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