Differentiate three basic components of utilization management as depicted in Figure
5.1 in Chapter 5 of your textbook.
Referral Management: this component determines which medical services that are
necessary, arranges the services which reduces the unnecessary utilization. The authorization
also allows the provider to determine if the health condition requires special treatment;
however, if it does, the provider can send referrals to a network specialist who can provide
care. These referrals are for a certain number of visits and are not open ended for a course of
treatment (Kongstvedt, 2020).
Precertification Management of Institutional Services: This is when a nurse requests
authorization for an elective outpatient procedure, the payer will then determine if the facility
is in network. The payer will then authorize the coverage of the procedure or not; if it is
approved, the payer will assign the expected length of stay as well. The facility that performs
the procedure will also check the precertification status before services are provided
(Kongstvedt, 2020).
Retrospective Utilization Management: this refers to utilization management related
activities that takes place after the care was performed (Kongstvedt, 2020). This confirms that
the care was appropriate and done in an efficient manner. During this review, it will
determine if the codes are accurate to the details of care. The review should uncover minimal
discrepancies with the information provided during the review process (Giardino et al.,
2023).
Explain the importance of drug utilization review and step therapy.
Drug utilization review (DUR) is an ongoing, systematic quality-improvement
activity and strategies for managing the volume and pattern of prescriptions (Kongstvedt, P.
R., 2020). As described by Kongstvedt (2020, p. 147), patients must demonstrate that they are
unable to take the less costly medication due to adverse reactions or an ineffective response.
If the more expensive medication is needed a prior authorization will most likely be required
before coverage is applied. Step therapy can play an important role in managing healthcare
costs. Additionally, Drug Utilization Review provides the quality assurance, feedback, and
corrective action. In order to reduce overall healthcare costs, pharmacists perform these
reviews.
Distinguish between disease management (DM) and case management.
Case management has costs that often exceed the routine costs and almost all insurance
companies have a case management program. However, it has the potential to provide
savings under the case management program (Kongstvedt, 2020). According to Kongstvedt
(2020), specially trained nurses will coordinate aspects of care for the members who have
chronic conditions that are not a part of the disease management program. Disease
Management Programs have been successful in empowering many individuals living with
chronic illnesses, such as chronic obstructive pulmonary disease (COPD), to assume greater
influence over their health and achieve improved health outcomes. According to our
textbook (Kongstvedt, P. R. (2020), disease management programs utilize computer programs
to analyze medical and drug benefit claims to diagnose, identify, and determine the level of
interventions that would be most appropriate for the patient.
