Homework Help is Here – Start Your Trial Now!
Business
Operations Management
cussed previously, utilization management refe igned to approve or disapprove care based on c does not prevent patients from obtaining the sen liable for the service if utilization management at of utilization management techniques on pag alth plans employ utilization management. Sel cechniques on page 2 of this document, and in u believe they would have on the Institute of M at is safe, effective, patient centered, timely, eft nis assignment, instead, you are to think critica ilization of healthcare services and its influenc ing harm to patients from the care that is intended to he roviding services based on scientific knowledge to al ervices to those not skely to benefit (avoiding underuser stered Providing care that is respectful of and respons and ensuring that patient values guide all clinical decis ducing waits and sometimes harmfut delays for both the Voiding waste, including waste of equipment, supplies Providing care that does not vary in quality because of ographic location, and socioeconomic status

cussed previously, utilization management refe igned to approve or disapprove care based on c does not prevent patients from obtaining the sen liable for the service if utilization management at of utilization management techniques on pag alth plans employ utilization management. Sel cechniques on page 2 of this document, and in u believe they would have on the Institute of M at is safe, effective, patient centered, timely, eft nis assignment, instead, you are to think critica ilization of healthcare services and its influenc ing harm to patients from the care that is intended to he roviding services based on scientific knowledge to al ervices to those not skely to benefit (avoiding underuser stered Providing care that is respectful of and respons and ensuring that patient values guide all clinical decis ducing waits and sometimes harmfut delays for both the Voiding waste, including waste of equipment, supplies Providing care that does not vary in quality because of ographic location, and socioeconomic status

Practical Management Science
Practical Management Science
6th Edition
ISBN:9781337406659
Author:WINSTON, Wayne L.
Publisher:WINSTON, Wayne L.
Chapter2: Introduction To Spreadsheet Modeling
Section: Chapter Questions
Problem 20P: Julie James is opening a lemonade stand. She believes the fixed cost per week of running the stand...
See similar textbooks
icon
Related questions
Question

I choose 

As discussed previously, utilization management refers to any clinical restriction on utilization designed to approve or disapprove care based on clinical necessity. Utilization management does not prevent patients from obtaining the services, but it simply states that the insurer is not liable for the service if utilization management procedures are not followed. Review the list of utilization management techniques on page two of this document. Reflect on the reasons health plans employ utilization management. Select two of the utilization management techniques on page 2 of this document, and in a minimum of 500 words, describe the impact you believe they would have on the Institute of Medicine's (IOMS) goals of healthcare that is safe, effective, patient centered, timely, efficient and equitable. No research is required for this assignment, instead, you are to think critically about the mechanisms used to control the utilization of healthcare services and its influence (positive or negative) on the IOMS goals. IOM Goals Safe: Avoiding harm to patients from the care that is intended to help them. Effective: Providing services based on scientific knowledge to al who could benefit and retraining from providing services to those not ikely to benefit (avoiding underuse and misuse, respectively) + Patient-centered Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide ail clinical decisions • Timely: Reducing waits and sometimes harmfut delays for both those who receive and those who give care. Efficient Avoiding waste, inciuding waste of equipment, supplies, ideas, and energy - Equitable Providing care that does not vary in quality because of personal characteristics such as gender. athnicity, geographic localion, and socioeconomic status
Transcribed Image Text:As discussed previously, utilization management refers to any clinical restriction on utilization designed to approve or disapprove care based on clinical necessity. Utilization management does not prevent patients from obtaining the services, but it simply states that the insurer is not liable for the service if utilization management procedures are not followed. Review the list of utilization management techniques on page two of this document. Reflect on the reasons health plans employ utilization management. Select two of the utilization management techniques on page 2 of this document, and in a minimum of 500 words, describe the impact you believe they would have on the Institute of Medicine's (IOMS) goals of healthcare that is safe, effective, patient centered, timely, efficient and equitable. No research is required for this assignment, instead, you are to think critically about the mechanisms used to control the utilization of healthcare services and its influence (positive or negative) on the IOMS goals. IOM Goals Safe: Avoiding harm to patients from the care that is intended to help them. Effective: Providing services based on scientific knowledge to al who could benefit and retraining from providing services to those not ikely to benefit (avoiding underuse and misuse, respectively) + Patient-centered Providing care that is respectful of and responsive to individual patient preferences, needs and values and ensuring that patient values guide ail clinical decisions • Timely: Reducing waits and sometimes harmfut delays for both those who receive and those who give care. Efficient Avoiding waste, inciuding waste of equipment, supplies, ideas, and energy - Equitable Providing care that does not vary in quality because of personal characteristics such as gender. athnicity, geographic localion, and socioeconomic status
• Preadmission certification, The insurer requires that nonemergency admitted to the hospital. preadmission certification. It specifies the number of hospital da a patient is authorized to stay. If a physician wants a patient to longer, additional days have to be requested. Retrospective review. This inpatient review is undertaken after the patient has been discharged. If the insurer determines that the paric should not have been admitted or should not have stayed so long, it will advise the provider to follow the insurer's admission protócols. • Denial of payment. This inpatient review is used in conjunction with retrospective review. If the patient should not have been admitted cr stays too long, the insurer will not pay for the inappropriate admission: or days. Mandatory second surgical opinion. This protocol requires the patient to obtain a second opinion before a nonemergency surgical procedure is undertaken. If the second opinion does not confirm the initial recommendation, the patient is typically left to decide whether the procedure should be done. • Case management. This program identifics high-cost cases. A case coordinator has authority to approve the substitution of some otherwise-uncovered services as lower-cost or more-appropriate alternatives to covered services. Home healthcare as a substitute for additional hospital days is an example. • Discharge planning. This program requires the provider to have a plan in place at the time of admission for the patient's care on discharge from the hospital. • Gatekeeper. This program assigns a primary care physician to cach subscriber. This physician must approve visits to a specialist or the insurer is not obligated to pay for the specialist visit.
Transcribed Image Text:• Preadmission certification, The insurer requires that nonemergency admitted to the hospital. preadmission certification. It specifies the number of hospital da a patient is authorized to stay. If a physician wants a patient to longer, additional days have to be requested. Retrospective review. This inpatient review is undertaken after the patient has been discharged. If the insurer determines that the paric should not have been admitted or should not have stayed so long, it will advise the provider to follow the insurer's admission protócols. • Denial of payment. This inpatient review is used in conjunction with retrospective review. If the patient should not have been admitted cr stays too long, the insurer will not pay for the inappropriate admission: or days. Mandatory second surgical opinion. This protocol requires the patient to obtain a second opinion before a nonemergency surgical procedure is undertaken. If the second opinion does not confirm the initial recommendation, the patient is typically left to decide whether the procedure should be done. • Case management. This program identifics high-cost cases. A case coordinator has authority to approve the substitution of some otherwise-uncovered services as lower-cost or more-appropriate alternatives to covered services. Home healthcare as a substitute for additional hospital days is an example. • Discharge planning. This program requires the provider to have a plan in place at the time of admission for the patient's care on discharge from the hospital. • Gatekeeper. This program assigns a primary care physician to cach subscriber. This physician must approve visits to a specialist or the insurer is not obligated to pay for the specialist visit.
Expert Solution
trending now

Trending now

This is a popular solution!

steps

Step by step

Solved in 2 steps

SEE SOLUTIONCheck out a sample Q&A here
Blurred answer
Knowledge Booster
Organizational buyers
Learn more about
Need a deep-dive on the concept behind this application? Look no further. Learn more about this topic, operations-management and related others by exploring similar questions and additional content below.
Similar questions
Recommended textbooks for you
Practical Management Science
Practical Management Science
Operations Management
ISBN:
9781337406659
Author:
WINSTON, Wayne L.
Publisher:
Cengage,
Operations Management
Operations Management
Operations Management
ISBN:
9781259667473
Author:
William J Stevenson
Publisher:
McGraw-Hill Education
Operations and Supply Chain Management (Mcgraw-hi…
Operations and Supply Chain Management (Mcgraw-hi…
Operations Management
ISBN:
9781259666100
Author:
F. Robert Jacobs, Richard B Chase
Publisher:
McGraw-Hill Education
Business in Action
Business in Action
Operations Management
ISBN:
9780135198100
Author:
BOVEE
Publisher:
PEARSON CO
Purchasing and Supply Chain Management
Purchasing and Supply Chain Management
Operations Management
ISBN:
9781285869681
Author:
Robert M. Monczka, Robert B. Handfield, Larry C. Giunipero, James L. Patterson
Publisher:
Cengage Learning
Production and Operations Analysis, Seventh Editi…
Production and Operations Analysis, Seventh Editi…
Operations Management
ISBN:
9781478623069
Author:
Steven Nahmias, Tava Lennon Olsen
Publisher:
Waveland Press, Inc.
SEE MORE TEXTBOOKS