Medical Utilization Management Analysis Techniques



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Medical Utilization Management Analysis Techniques

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Acute Care Utilization Management in Managed Care … – Texas OIG

oig.hhsc.texas.gov

Aug 16, 2016 Through utilization management, MCOs assess the medical necessity, efficiency,
and appropriateness of health caretechnique used by MCOs to verify covered
benefits, determine medical necessity, and assist with the … areas for
improvement through review and analysis of utilization management data.

Acute Care Utilization Management in MCOs … – OIG – Texas.gov

oig.hhsc.texas.gov

Nov 30, 2016 WHY THE IG CONDUCTED. THIS AUDIT. Superior is the largest managed care
organization (MCO) in Texas, and is contracted to provide Medicaid and. CHIP
health care services in most areas of the state. Approximately 84 percent of
Medicaid and CHIP enrollees are members of an MCO, and at nearly …

Acute Care Utilization Management in MCOs: FirstCare Health Plans

oig.hhsc.texas.gov

Feb 21, 2017 state, and federal requirements, and FirstCare performs analysis of utilization
management …. acute care utilization management practices in ensuring that
health care services provided are. (a) medically ….. A method for periodically
reviewing and amending utilization management clinical review criteria.

Health Care in America – Centers for Disease Control and Prevention

www.cdc.gov

Robin E. Remsburg, Ph.D., A.P.R.N., Chief, Long-Term Care Statistics Branch.
Charles A. Adams, Chief, Technical Services Branch. Suggested citation:
Bernstein AB, Hing E, Moss AJ, Allen KF, Siller AB, Tiggle RB. Health care in
America: Trends in utilization. Hyattsville, Maryland: National Center for Health
Statistics. 2003 …

Health Utilization Management Standards, Version 6.0 – the Illinois …

insurance.illinois.gov

Core Standards incorporate the basic elements necessary to promote quality for
any type of health care … programs. For example, an applicant may choose to
apply for Utilization Management (UM) accreditation initially …. o Reports with
data or analysis demonstrating non-compliance (e.g., not meeting timelines,
wrong.

Quality Improvement & Utilization Management Program Evaluation

www.floridahealth.gov

The goal of the Children's Medical Services (CMS) Managed Care Plan Quality
Improvement. Program (QI … reviews and approves QI, Utilization Management (
UM) policies and procedures, Risk. Management (RM), clinical …. Through
analysis of the enrollees served, CMS has developed an asthma and diabetes
Chronic.

Workplace Wellness Programs – United States Department of Labor

www.dol.gov

participation and utilization among employees. This report will be of interest to
national and state policymakers, employers and wellness program vendors,
employer and employee advocacy organizations, health researchers, and others
with responsibilities related to designing, implementing, participating in, and
monitoring …

Health Information Technology: a Tool to Help … – HealthIT.gov

www.healthit.gov

Health care professionals like you play a vital role in improving the health
outcomes, quality of care, and the health … Health IT can help health care
professionals to do what you do best: provide excellent … Patient lists by clinical
condition, patient registries, and panel management analysis tools allow you and
others in your.

AHCCCS Medical Policy Manual (AMPM), Chapter 1000

www.azahcccs.gov

Jul 1, 2016 MM Utilization Data Analysis and Data Management b. Concurrent Review c.
Discharge Planning d. Prior Authorization (PA) e. Inter-Rater Reliability f.
Retrospective Review g. Clinical Practice Guidelines h. New Medical
Technologies and New Uses of Existing Technologies i. Case Management/Care
 …

2016 Independent Medical Review (IMR) Report: Analysis of 2014 …

www.dir.ca.gov

Appendix O: 53 IMR Cases by FDL Year, Method of Selection, and Opioids ………..
. 41. Appendix P: IMR Reviewer … Evaluation and Management requests, such
as specialist consultations and dental … applied the guidelines of the Medical
Treatment Utilization Schedule (MTUS) in the majority of treatment evaluations, …

Beyond EMS Data Collection – EMS.gov

www.ems.gov

Jul 12, 2016 Robert Bass, Retired EMS physician and State EMS director, representing EMS
Compass Project … Donna Clark, Golden Hour, VP of Customer Relationship
Management, representing Association …… and mentors and data-collection and
analysis tools (surveys, software, matrixes) in support of.

medical data mining – NIST

www.nist.gov

Dec 13, 2012 Healthcare management (provider care practices). • Fraud and abuse … and
retrieval includes streaming, batch processing, utilization, etc. … and Platforms. •
Helpful but not necessary for analysis. •Relevant to data veracity/quality. Tools /
Applications. 16. Understanding and Then Tackling the Pieces!

Managed Mental Health Care – SAMHSA Store

store.samhsa.gov

May 20, 1993 tal health care: Findings from the literature, 1990–2005 (DHHS Pub. No. …..
Managed care techniques include the defini- tion and interpretation of medical
necessity, utilization management, and prospective payment methods. … Section
III of this report describes the research methods used in the analysis.

Joint HHS, CMCS, HRSA, and CDC Informational … – Medicaid.gov

www.medicaid.gov

Dec 1, 2016 people living with HIV, 42% of PLWH who were receiving HIV medical care in
2013 were insured through. Medicaid. …. For example, in a recent analysis,
Fleishman et al. found that the average annual ….. Additional strategies states
may consider to ensure that utilization management techniques are.

Use of Real-World Evidence to Support Regulatory Decision … – FDA

www.fda.gov

Aug 31, 2017 Submit written comments to the Dockets Management Staff, Food. 2 and Drug ….
healthcare claims databases) can be used as data collection and analysis
infrastructure to support many types of trial designs, … criteria or other scoring
tools for making a determination about the suitability of RWD or RWE.

The National Public Health and Medical Situational … – PHE.gov

www.phe.gov

deliberate actions that, in turn, may result in better resource utilization, successful
mitigation of domestic and …. 4 As defined in the Public Health and Medical
Situational Awareness Strategy, Department of Health and Human …..
management tools can produce better PH&M SA decision support products for
prompt and.

GAO-13-441, VA Health Care: Management and Oversight of Fee …

www.gao.gov

May 31, 2013 was due to VA's adoption of Medicare rates as its primary payment method for fee
basis providers. VA's fee basis care utilization also increased from about.
821,000 veterans in fiscal year 2008 to about 976,000 veterans in fiscal year.
2012. Total VA Fee Basis Care Spending, Fiscal Years 2008 through …

Care Management Workbook – State of New Jersey

www.nj.gov

Care Management Process Tools: 1. … The Division of Medical Assistance and
Health Services' (DMAHS) core quality mission is to develop and … Management.
Re-Assess. Members. Needs. (Ongoing). 3. Develop. Care Plan. 2. Assess. Care
Needs of Member. 6. Modify. Plan based on Analysis. 5. Analyze. Plan.