We are looking to identify the best fit for the utilization management process where a decision is made on the next steps for some type of planned or requested event.
The definition that best explains how we are going to use Utilization Management data is outlined here:
The Institute of Medicine (IOM) Committee on Utilization Management by Third Parties recognizes UM as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.”
We are looking to see if this should be mapped to a procedure request or to some other request type. The essential use cases we will drive are based on state:
Prospective review is conducted at the onset of a service or treatment and is also referred to as precertification or prior authorization. This review is performed before care is rendered in order to eliminate or reduce unnecessary services. Prospective review may have the impact of not authorizing or limiting care that had been recommended by the evaluating provider(s).
Concurrent reviews performed during the course of treatment or episode of care. Intervention occurs at varied intervals and may encompass case management activities such as care coordination, discharge planning, and care transitioning. Concurrent review may have the impact of curtailing an existing episode of care.
Retrospective review is conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria. Such reviews often relate to payment and may result in denial of a claim. Financial risk for a retrospective denial is often borne by the provider.