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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 ...
URAC is a Washington, DC–based non-profit organization [1] that provides accreditation of organizations involved in medical care services, as well as education and measurement programs. Founded under the name Utilization Review Accreditation Commission in 1990, the name was shortened to the acronym URAC in 1996. [2]
The program started as a way to provide educational intervention to physicians who were identified by the Board and had received ethical infractions. By 1996, the ProBE Program had been endorsed by 45 licensing boards and sub-specialty boards throughout the United States. In 2007, CPEP acquired The Ethics Group, LLC, and began offering the program.
Formal utilization review and quality improvement programs including disease management and case management; An emphasis on preventive care including wellness incentives and patient education; The techniques can be applied to both network-based benefit programs and benefit programs that are not based on a provider network.
Individual physicians are employed by the group practice, rather than by the HMO. The group practice may be established by the HMO and only serve HMO members ("captive group model"). Kaiser Permanente is an example of a captive group model HMO rather than a staff model HMO, as is commonly believed.
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).
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).
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 ]