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Valencia College, Osceola *

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Electrical Engineering

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Apr 3, 2024

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https://lti.cognella.com/h5p/embed.php?url=https%3A%2F%2Flti.cognella.com%2Fpluginfile.php %2F115882%2Fmod_h5pactivity%2Fpackage%2F0%2Fch05- 1291372958097468528.h5p&preventredirect=1&component=mod_h5pactivity Basics of Health Insurance and Managed Care Lecture Study Notes Chapter 5: Utilization Management To help you prepare for quizzes and exams, you may complete these “fill in the blank” Lecture Study Notes as you review each lecture.  You have 2 options on how you may use these notes: Export the notes before beginning the lecture by clicking "Export your study notes" on the final slide. This allows you to print out the file with blanks so you can fill in the answers as you go through the lecture; or Open a second screen tab to fill in the lecture notes electronically while you listen to the lecture and then export it after you have completed the lecture. In this case the file prints with your answers. Note: If you exit this webpage, your work will not be saved. If you would like to save your work, click "Export your study notes" on the final slide. Enter your name and date below: Refresher 1. Fill in the blanks.  What is utilization management according to the lecture?  Utilization management is a system used to review the medical ______________, appropriateness, and reasonableness of services to be provided, or that have been provided, to patients.  If services are determined not to meet these criteria, an insurance company may _________ the service or the claim. What is Utilization Management? 2. Fill in the blank. What is the goal of UM?  To see that each member receives the ______________ level of care at an appropriate cost. 3. Fill in the blank.  Utilization management is not about health plans always telling members _______. (Rather it is about health plans denying payment for the service.  The patient can always go forward with a service.) 4. Fill in the blanks.  What are the three areas of UM focus? Review of functions to determine whether a service is or should be _________________ under the benefits plan, and under what __________________ Activities designed to facilitate necessary services at the lowest _____________ cost Services that best improve health ____________________ Healthcare System Challenges 5. Fill in the blanks.  What two healthcare system challenges does UM help address? Ensures that patients get needed healthcare without ______________ so much that society limits spending on other social objectives, such as education. Discourages unnecessary and _________________ healthcare services without risking ________________. Importance of Evidence-Based Medicine 6. Fill in the blanks.  What is evidence-based medicine? Practice _________________ based on clinical evidence that supports __________________ decisions for positive health outcomes.

7. Name three things that are included as part of evidence-based medicine (EBM). 9. Fill in the blanks.  How can health plans use cost-sharing in benefit design to impact utilization?   Cost-sharing can be used to reduce utilization in some areas such as ________________ room use for non-emergencies; and to increase utilization of wellness and ______________________. Benefit Design 8. Fill in the blanks.  How do health plans use EBM in designing benefits?  Plans use EBM to determine: What __________________ should be covered. Appropriate __________________ in which services should be covered. Specific _____________________ in which services should be covered. Specific providers that can provide covered _______________________. What services are considered experimental or _______________________. Type of Benefit Exclusions 10. Name four typical benfit exclusions. Methods of Utilization Management 11. What are the four methods of utilization management? Prospective Review 12. When does prospective review typically begin? 13. Is UM’s focus on being proactive or reactive? 14. Name some common prospective review tools. 15. Fill in the blanks.  What is demand management?  Aims to offer ________ costly services, provide __________, and promote ________________ to reduce the demand for costly services. Prospective Review, cont. 16. Name three examples of demand management techniques. 17. Name four examples of when prospective review is used.

18. Why do insurance companies use prospective review? Concurrent Review 19. When does concurrent review typically begin? 20. Fill in the blanks.  For what purposes is concurrent review used?  To determine the ________________ of services or number of ____________ during a hospital stay. To review care decisions for efficiency and to plan ahead for ________________. To consider alternative _______________ of care and need for _____________ services and possible benefits of home support. To monitor the patient’s __________________. Concurrent Review, cont. 21. Name some common concurrent review tools. 22. When is concurrent review used? 23. Fill in the blanks.  For what purposes is concurrent review used?  To review medical _______________________. To shorten the length of ________________ stays. To substitute other types of ________________. Retrospective Review 24. When does retrospective review typically begin? 25. Fill in the blanks.  Name three common retrospective review tools. __________________: used for life threatening emergencies or when patient or provider have not followed authorization system protocols __________________: cases examined for appropriateness, billing errors, etc., which may prompt further investigation by the plan and/or a payment adjustment __________________: uses utilization data to identify patterns (findings may be used to develop plan or provider report cards and/or prove fraud). Retrospective Review, cont. 26. How is coding used in retrospective review decision making?

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27. What is upcoding? 28. What is unbundling? 29. When is retrospective review used? Retrospective Review, cont. 30. Fill in the blanks.  For what purposes is retrospective review used? To review medical _______________________ and whether benefits are covered. To validate whether the appropriate _____________ of care was provided. To deny _____________________ if services are not covered. 31. Who may challenge denials? 32. Who provides the last level of appeals? 34. In general, are nurses able to authorize denials (yes or no)? Utilization Management Nurse 35. Name four examples of tasks that are performed by UM nurses. 36. Do health plans, hospitals, or both employ UM nurses? Utilization Management Team 33. Who conducts each stage of the utilization management assessment? Utilization Management Physicians 37. What are two functions that are performed daily by UM physicians? 38. Are UM physicians bound by the health plan’s criteria and rules (yes or no)? 

Case Management 39. Fill in the blanks.  What is case management?  It is a method of utilization management that uses the process of assessment, _____________________, facilitation, and care coordination to meet the healthcare needs of an individual patient and his or her family through communication and the provision of needed _______________ to promote good health outcomes.  The focus in this utilization management method is on the needs of the ______________ patient. 40. Fill in the blanks.  What are the three goals of case managers? To ensure patients receive medically-necessary services _________________ That services are of high ________________ That care is provided efficiently and _____________________ Cae Management, cont. 41. Fill in the blanks.  What are the three responsibilities of case managers? Coordinate care and health _________________ among all providers involved Make telephone calls with the patient member so the treatment ___________ is followed Anticipate ________________ healthcare needs to ensure access Disease Management 42. Fill in the blanks.  What is disease management?  It is a method of utilization management that provides  _______________ programs to a ___________________ with a specific _________________ conditions.  Typically, these health plan programs target members with ____________ chronic conditions.  These programs aim to improve health while __________ costs associated with __________________ complications, such as hospitalizations. 43. Name four examples of common disease management programs. 44. Fill in the blanks. What are four steps that are typically used by insurance companies in disease management programs?  _______________ members with the disease management program’s chronic condition Provide practice guidelines and clinical evidence to patients and __________________ Support provider collaboration by use of a __________________ team Education on patient ___________________ Key Terms Case Management (CM) = a method of utilization management that uses the process of assessment, planning, facilitation, and care coordination to meet the healthcare needs of an individual patient and his or her family through communication and the provision of needed resources to promote good health outcomes. The focus in this utilization management method is on the needs of the individual patient. Concurrent Utilization Management = utilization review that is performed during an episode of care or the course of treatment. Demand Management = strategy to offer less expensive healthcare services and promote self-care to reduce the demand for more expensive services. Examples may include nurse advice lines and self-care programs. Disease Management (DM) = a method of utilization management that provides support programs to a population with a specific chronic health condition. Typically, these health plan programs target members with costly chronic

conditions, such as heart disease, asthma, and diabetes. These programs aim to improve health while reducing costs associated with avoidable complications, such as hospitalizations. Discharge Planning = a process that identifies the healthcare needs of patients once they leave the hospital in an effort to reduce future hospital readmissions. This process begins once a patient is admitted to a hospital, and continues until discharge. Evidence-Based Medicine (EBM) = practice guidelines based on clinical evidence that supports treatment decisions for positive health outcomes. Pattern Analysis = approach used by insurance companies to identify, assess, and take action when there are variations in provider practice patterns that may negatively impact quality and/or cost. Prior Authorization or Precertification = the decision made by a health insurance company as to whether a healthcare service, treatment plan, medication, or equipment is medically necessary, prior to the rendering of care. Prospective Utilization Management = utilization review that is performed prior to an episode of care or the course of treatment. This type of review includes precertification and prior authorization. Retrospective Utilization Management = utilization review that is performed after an episode of care or the course of treatment services is provided. Such reviews are often in the form of payment of claims, in which case an insurance company may deny payment of a claim. Unbundling = when multiple claims are submitted by separating service components and charging for each separately. Upcoding = when a claim is submitted for a service or diagnosis that is more complex, resulting in higher payment. Utilization Management (UM) = system to review the medical necessity, appropriateness, and reasonableness of services that are to be provided, or have been provided, to patients. If services are not determined to meet these criteria, an insurance company may deny the service, or the claim, if the service has already been rendered

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