What is the difference between case management and utilization management

Facilitates a relationship between the family and the patient to enable them to take informed decisions. On completion of the program the certificate is issued if the candidate has a current valid RN license, has an experience of two years as a full-time RN, and has worked for hours as a case management nurse in the last three years. Though the additional training is not always compulsory, jobs in specialized health care settings do require the specialty training.

Skills required to be a successful case management nurse include all skills required of a medical job, communication skills, the ability to respond quickly to medical emergencies.

The case management nurse is expected to gain knowledge about diagnosis related group codes DRGs , develop critical thinking, be observant and keen and improve the ability to analyze. Certified case managers are always paid a higher salary than other nursing professionals.

Role of a Utilization Review Nurse A utilization review nurse reviews individual medical cases to ensure that they are getting the most effective care.

The number of reviews are rising, as are denials of coverage. The process steps required by insurers can be perceived as red tape or unnecessary by healthcare workers. Physicians may not well-receive the results of retrospective reviews. Even with UM in place, the cost of care is still high, so it may be seen as ineffective. There is non-response or non-payment from an insurer sometimes called de facto denial.

Doctors may see these tests as important, but insurers might not have the same view. The number of insurance providers and the coverage available may cause costs to fluctuate. There may be a difference between the best practice and most cost-effective treatment, which can create a conflict between doctors and insurance companies.

The process can be burdensome on medical staff, taking them away from time that could be better spent with patients. Review criteria are often hidden from doctors and patients, so they may not know why coverage is denied.

UM may not have as big an effect as was once thought. Prescribed treatments that are unproven or investigational. However, treatments are constantly under evaluation, so something denied today may be covered in the future. Lack of medical necessity of a treatment. Technical errors in the documentation, such as missing or incomplete information. Approve the treatment if criteria are met; deny it if not. If denied, the physician can appeal. Implementing a Utilization Management Program It takes a lot of time and effort for a healthcare provider to implement a UM program.

The following questions will help guide the implementation of a UM program to ensure it meets goals and operates properly: How will the utilization management program limit unneeded utilization and contain costs? What are the potential consequences both positive and negative of bringing outside parties into the patient care decision-making process? Will current processes hold utilization management organizations and purchasers accountable for their actions, or will you require new forms of oversight?

What are the responsibilities of healthcare providers and patients? What are the responsibilities and authority of case managers and care managers on the UM committee? How will you educate patients and staff about the value of UM? UM Components and Techniques Utilization management is a complex process that has many moving parts.

Keep the following in mind: Ensure the privacy and confidentiality of patient medical information. Treatment decisions will need to be reviewed and communicated in a timely manner, so delegate tasks and create a responsibility matrix that you can manage.

Justify the medical necessity of admissions, extended stays, and professional services. Create a feedback process to evaluate the effectiveness of clinical criteria as well as satisfaction with the process. When an insurer denies treatment, having a review board to process and collaborate with patients will expedite responses i. When decisions are appealed, a program should be in place that will allow data to be gathered to support the appeal. ICD is a list of codes used to classify symptoms and diseases; because it is used internationally, using it as part of UM will help with communication.

Proactively work to ensure that clinical documentation supports proposed courses of treatment. Processes need to be evidence-based, so they will require data gathering and verification tools. Be prepared for external audits. Ensure that payers and insurers share data in a timely manner. Incorporate tools to identify high-risk patients and their impact on the process.

Education is crucial for effective utilization management, so set up programs for patients and staff. Include administrative requests for clinical case reviews. Team-based care works well with UM. Primary care physicians should lead teams that work to their highest level, communicate with patients before, during, and after in-person office visits, have systems in place to identify gaps in care, preventive needs, and clinical pathways, work to support process improvement, and look for system-level trends.

High Cost Case Management High cost cases — those in which a small number of patients or beneficiaries generate a large portion of covered medical expenses — can cause headaches for insurers. Pharmaceuticals in Utilization Management There are some aspects of utilization management that are specific to prescribing drugs and tracking their effects. Utilization Management versus Utilization Review The two terms are occasionally used as synonyms.

URAC Standards for Utilization Management URAC which originally stood for Utilization Review Accreditation Commission, but now has no official meaning is a non-profit organization that runs accreditation programs for many areas of healthcare they also provide education programs.

Utilization Management Plan Template Because UM is such an involved and intertwined set of processes and procedures, a simple template would not be helpful. People and Entities Involved in Utilization Management In addition to the nurses, doctors, hospitals from small town clinics to well-known facilities like the Mayo Clinic , their staff including program managers, medical directors, and referral coordinators , private insurance companies e.

Medicare: A government-run insurance program for people 65 and older. Medicaid: A government-run insurance program for low income people. They are health insurance companies that contract with healthcare providers for reduced rates. Health Maintenance Organization HMOs : Another type of managed care that provides both insurance and healthcare, or works with closely-affiliated entities for healthcare.

Kaiser Permanente is a well-known HMO. HMOs are sometimes called integrated delivery systems, and they drove the growth of UM in the s. Example: The patient may have Medicare and insurance through his employer.

The primary insurance is the one the preauthorization request would go through. Verify that the requested service is a covered benefit under the insurance contract. If it is a covered benefit, determine if it requires preauthorization. Example: Bariatric surgery may be a contract exclusion.

If it is a covered benefit, it may require preauthourzation. Gather clinical information needed to determine if criteria is met for this service. Review of clinical information to determine if it meets criteria for medical necessity, and level of care. Behavioral connectivity: An emerging unmet need for case management Consumer behaviors and social circumstances account for 55 percent of the determinants of premature death, the remainder being genetic predisposition, and environmental factors and health.

Case managers are well-positioned within the healthcare system to facilitate patient and caregiver engagement; improved health outcomes and lower costs are likely. Registered nurses critical to case and utilization management In , there were approximately 2.

The magnitude of nursing shortages at the national level remains unclear. Recent forecasts vary widely, with a projected shortage of , nurses by Digital Commons to a surplus of , by Bureau of Health Workforce. Recruiting experienced case and utilization managers may be increasingly challenging given the attrition rate and shortages in selected states. A disciplined and organized care management process focused on generating quality outcomes across the continuum is essential.

Fully-staffed utilization and case management programs are the linchpin to the emergence of a seamless, fully integrated care delivery model that is better able to: match patient acuity with the appropriate level of post-acute and outpatient care; manage transitions among alternative sites of care; facilitate evidence-based approaches to minimize gaps in care; and promote patient caregiver self-management.

Essential elements of utilization and case management include human capital strategies i. Personnel are immediately available to organizations with short-term operational and longer-term, strategic needs. Our CSS team is able to support the operational needs of providers and payers across the entire care continuum.