Utilization Management

Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.

Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.

As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review. While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is prospective and intends to manage health care cases efficiently and cost effectively before and during health care administration. Utilization review is more retrospective considering whether health care was appropriately applied after it was administered.

There are four basic techniques in utilization management:

1. Demand Management
2. Utilization Review
3. Case Management
4. Disease Management