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UM is the evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines, and under the provisions of an applicable health insurance plan. Typically, UM addresses new clinical activities or inpatient admissions based on the analysis of a case.
UM criteria are medical guidelines which may be developed in house, acquired from a vendor, or acquired and adapted to suit local conditions. Two commonly used UM criteria frameworks are the McKesson InterQual criteria [23] and MCG (previously known as the Milliman Care Guidelines). [24]
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Milliman, formerly Milliman & Robertson, is an international actuarial and consulting firm based in Seattle, Washington. The company was founded in 1947, by Wendell Milliman and Stuart A. Robertson and operates 59 offices internationally, with over 3,000 employees.
Plates vi & vii of the Edwin Smith Papyrus (around the 17th century BC), among the earliest medical guidelines. A medical guideline (also called a clinical guideline, standard treatment guideline, or clinical practice guideline) is a document with the aim of guiding decisions and criteria regarding diagnosis, management, and treatment in specific areas of healthcare.
Most CCRCs require both health and financial assurances for admission. As seniors progress in age, and medical needs change, the level of nursing care and service increases proportionally in response. In such a way, the needs of seniors are consistently monitored and catered to, particularly as those needs become more intensive.
Medical audit is a focused study of the process and/or outcomes of care for a specified patient cohort using pre-defined criteria. Audits are typically organized around a diagnosis, procedure or clinical situation. [28] [29] It remains the predominant mode of peer review in Europe [30] and other countries. [31] [32]
"Influential people are once again twisting the truth about vaccines for their own gain," writes Eleanor Menzin.