Medical Utilization Management

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Medical Utilization Management

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VHA Directive 1117 Utilization Management … – Veterans Affairs

Jul 9, 2014 Establishes policy for VHA's Utilization Management (UM) Program, an integral
component of VHA's integrated framework to ensure quality, safety, and value
across the care continuum. … providers, include the forward-looking evaluation of
the appropriateness, medical need, and efficiency of health care …

Utilization Management as a Cost-Containment Strategy –

Utilization management (UM) is now an integral part of most public and private
health plans. Hospital review, until recently the primary focus of UM, is associated
with a reduction in bed days and rate of hospital cost increases. These reductions
appear to have had limited impact on aggregate health care costs because of.

Health Utilization Management Standards, Version 6.0 – the Illinois …

Quality-based operations should be the centerpiece of any company doing
business in today's health care system. Quality improvement activities promote a
wide range of benefits such as increasing operational efficiencies, reducing
business risks and improving patient health outcomes. However, health care
professionals …

Acute Care Utilization Management in MCOs … – OIG –

AUDIT. Superior is the largest managed care organization (MCO) in Texas, and
is contracted to provide Medicaid and. CHIP health care services in …

Acute Care Utilization Management in Managed Care … – Texas OIG

Aug 16, 2016 receive applicable health care services, and that state and federal funds spent on
managed care are used appropriately. The IG Audit Division is conducting a
performance audit to evaluate the effectiveness of MCO acute care utilization
management practices in ensuring that health care services provided …

Acute Care Utilization Management in MCOs: FirstCare Health Plans

Feb 21, 2017 MCO acute care utilization management practices in ensuring that health care
services provided are (a) medically necessary, (b) efficient, and. (c) comply with
state and federal requirements. WHAT THE IG RECOMMENDS. HHSC should
require FirstCare to strengthen its utilization management functions …

Acute Care Utilization Management in Managed Care … – Texas OIG

Aug 15, 2017 services for medical necessity, appropriateness, timeliness, effectiveness, and
compliance with state and federal requirements. The IG Audit Division conducted
four audits of acute care utilization management in MCOs to evaluate the
effectiveness of MCO acute care utilization management practices in.

Quality Improvement & Utilization Management Program Evaluation

1.1 Quality Improvement and Utilization Management Review Summary. The
goal of the Children's Medical Services (CMS) Managed Care Plan Quality
Improvement. Program (QI Program) is to assure high-quality care and services
for our enrollees by aggressively seeking opportunities to improve the
performance of our …

Health Care in America – Centers for Disease Control and Prevention

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 …

quality improvement / utilization management manual – Los Angeles …

program helps to ensure quality services by monitoring adherence to the
guidelines established within the Quality Improvement program, including
processes involving verification of DMC eligibility and medical necessity criteria,
as well as …

Vermont Medicaid Quality Management Plan – Department of …

underutilization and overutilization of services, and assessing the quality and
appropriateness of care furnished to beneficiaries with special health care needs.
While there are important roles for everyone involved with the DVHA in the
quality assurance and performance improvement program, much of the formal
quality …

Non-Discrimination in Benefit Design – Ohio Department of Insurance

Utilization management. •. Cost-sharing. •. Medical necessity definitions. •. Drug
formularies. •. Visit limits. Each of these features has the potential to be either
discriminatory or an important element in a QHP's quality and affordability,
depending on how the feature is designed and administered. CMS has identified
examples …


Utilization review” means a set of formal techniques designed to monitor the use
of, or evaluate the clinical necessity, efficacy, and/or efficiency of, health care
services, procedures or settings. Techniques may include ambulatory review,
prospective review, second opinion, certification, concurrent review, case
management …

Massachusetts PACE Report –

May 4, 2015 There was limited ability, either using the electronic medical system or through
tracking of utilization management (UM) decisions to consistently report, track,
and trend UM activities for quality of care, outcomes, and business planning
purposes. As PACE providers continue to develop their use of EMR, …

ASAM Clinical Justifications – State of New Jersey

Tips to Get Your Clinical. Authorization Approved By The IME. Provider Training.
New Jersey State Division of Mental Health and Addiction Services. (DMHAS).
The Division of Medical Assistance and Health Services (DMAHS) and. Rutgers
University Behavioral Health Care. IME Utilization Management Unit …

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

May 31, 2013 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 2012. GAO
found that several factors affect VA medical centers' (VAMC) utilization …

Alabama Medicaid Medical and Quality Review Services and Qualis …

What We Do. • Contract with Alabama Medicaid for utilization management and
quality review of healthcare services, equipment and supplies provided to
Medicaid recipients. • Answer clinical and technical questions related to
utilization management services and processes. • Offer telephonic and onsite
provider education.

R-9 Long Term Care Utilization Management –

Nov 1, 2016 puts the Department at the risk of loss of federal financial participation (FFP) and
disallowances. Utilization Management (UM) is the evaluation of the
appropriateness and medical need of health care services and procedures
according to evidence-based criteria or guidelines. Typically, UM addresses new.