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Utilization Review and Quality Management

 Utilization review is a process that insurance companies utilize to determine if a treatment is appropriate and review the request for the treatment. Quality management is a service that ensures an organization’s services is consistent.

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The key elements in utilization review

“The purpose of the review is to confirm that the plan provides coverage for your medical services. It also helps the company minimize costs and determine if the recommended treatment is appropriate.” (Garden and Insurance, 2018) Typically utilization review involves the review of past medical history. Utilization review helps insurance companies create guidelines on treatment for conditions. This process helps determine the most appropriate treatment for conditions based on physician’s recommendations, labs, and test results.

Another part of utilization review is that the patient’s wants may also be balanced with the needs. The first thing that is important to provide efficient and cost-effective healthcare. The wants of the family also need to be considered to provide comfort along with adequate care. Utilization review is also called utilization management. One of the main elements of utilization review is to provide preventative care and screening. Also, if a patient is admitted itis a goal to get them placed as soon as possible once the patient requires a lower level of care.

There are three main elements to utilization review prospective, concurrent and retrospective. According to Utilization Review prospective review is getting pre-approved for an elective procedure. Concurrent review is authorization for a service as it is happening. Retrospective review is when a patient seeks review after the service or procedure has already been performed.  

The key elements in quality management

Quality management assures success and patient satisfaction. Quality management procedures are in place to reduce waste, lower costs, engage staff, and identifying training opportunities. (, 2018) This system is in place to ensure patient satisfaction. Quality management is in place to make sure patients receive the highest quality of care and treatment. In most states, HMOs and POS plans are required to have quality management programs.

There are three major categories of quality management Donabedian’s classic model of quality management. This model consists of structure, process, and outcome. Quality management also consists of 6 goals, safe, effective, patient-centered, timely, efficient, and equitable. These goals were created by the Institute of medicine. According to page 180 of Health Insurance and Managed Care many HMOs have worked to incorporate these goals but these goals are provider oriented. One of the key elements of quality management is structure. The structure is about the context that care is given.

Process focusses on how care is given. Typically process studies are limited to data that is obtainable through the payer’s claims. (Kongstvedt, P. R. (2016)). Outcome is focused on the outcome of care. The outcome focusses on if certain treatments were successful or unsuccessful in specific diseases. According to page 183 of Health Insurance and Managed Care outcome studies typically focus on specific conditions like heart disease and if the medication is effective. Quality management focuses on

Compare and contrast

Quality management and utilization review are very similar. They both are utilized to make sure patients receive proper and high-quality care. Utilization reviews focus on the quality of care and quality management focuses on how the patients receive care. They are similar because they both focus on the care of the patients. Both quality management and utilization review are utilized to assist in determining what insurance companies will cover for treatment, and if the treatment is successful. Both quality management and utilization review are used by insurance companies. They are different because they are different processes. They focus on different aspects of treatment, care, and common diseases. Another thing that makes them similar is that they both of have changed over time.

How have quality management and utilization review changed over time

Quality management started in the 1920s. According to History of Total Quality Management (TQM). (n.d.). Businesses separated the processes of planning and carrying out the plan. In the 1950s “W. Edwards Deming taught methods for statistical analysis and control of quality to Japanese engineers and executives.”(History of Total Quality Management (TQM). (n.d.). From there Japan had great success in quality management. And soon surpassed the United States in quality measures.

Soon after the government created clear and concise guidelines and create the Malcolm Baldrige Award. Today those same standards apply and countries all over the world compete for awards. These standards have made quality management, what it is today. Unlike quality management I was not able to find a past history of utilization review.

Quality management and its role in managed care

            According to page 179. Of Health Insurance and Managed Care, all HMO’s are required to have quality management programs. Quality management programs are required by state law and regulations and only apply to insured plans. Medicare and Medicaid are also required to have quality management programs. Not all insurers are required to have quality management programs. Self-funded employer groups are not required to have a plan, nor are MediGap.

            Because of this quality management has a major part of managed care because it affects how health care is delivered. Quality management has a large impact on healthcare and how it is performed. Managed care being required to implement a quality management program is a great thing because it ensures customers are receiving high-quality care. Quality management programs look at a specific condition or medical care.

Utilization review and its impact on managed care

            Utilization has impacted manage care organizations because utilization review helps control the healthcare cost determine the treatment and care of diseases. Utilization utilizes a measurement system for managed care. In managed care, many statistics are given a per member per year or per member per month. These measurements refer to the average number of times something happens. Managed care organizations use different measuring systems to determine the proper treatment of specific diseases and utilize them to determine statistics.

Do the functions add value to managed care?

            I do think that these functions have helped managed care. I think without utilization review and quality management health ensure costs, and the cost of healthcare would be even higher than it is today. These functions help determine the amount that insurance companies cover and without that I do not believe they would cover as many medications or treatments as they do today. These processes are needed to develop quality and effective care. I do think that without these processes managed care would not be as successful as it is. I think utilization review and quality management do add a lot of value to managed care. I think utilization review ads a lot to managed care because it helps determine the most appropriate treatment for conditions based on physician’s recommendations, labs, and test results. I think quality management is important to managed care because it helps make sure patients receive high-quality care. Quality management ensures patients are receiving care correctly. 

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