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Utilization management is "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," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
Aging populations, a changing disease spectrum, and the progress and change in technology of health care become the major problems which lead to increasing of health care costs. [4] Then, how to use drug utilization evaluation and drug economy evaluation to improve and optimize the allocation of medical and health resources is a major problem ...
The Healthcare Cost and Utilization Project (HCUP, pronounced "H-Cup") is a family of healthcare databases and related software tools and products from the United States that is developed through a Federal-State-Industry partnership and sponsored by the Agency for Healthcare Research and Quality (AHRQ).
The Andersen healthcare utilization model is a conceptual model aimed at demonstrating the factors that lead to the use of health services. According to the model, the usage of health services (including inpatient care, physician visits, dental care etc.) is determined by three dynamics: predisposing factors, enabling factors, and need.
After a request comes in from a qualified provider, the request will go through the prior authorization process. The process to obtain prior authorization varies from insurer to insurer but typically involves the completion and faxing of a prior authorization form; according to a 2018 report, 88% are either partially or entirely manual.
An independent medical review (IMR) is the process where physicians review medical cases in order to provide claims determinations for health insurance payers, workers compensation insurance payers or disability insurance payers. Peer review also is used in order to define the review of sentinel events in a hospital environment for quality ...
URAC is a Washington, DC–based non-profit organization [1] that provides accreditation of organizations involved in medical care services, as well as education and measurement programs. Founded under the name Utilization Review Accreditation Commission in 1990, the name was shortened to the acronym URAC in 1996. [2]
Executive branch agencies and departments nominally under the authority of the Governor include: [1] [2] Agency for Health Care Administration (AHCA); Florida Board of Governors