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What’s in a Name? – Utilization Management

CareNational specializes in the Medical Management segment of healthcare, meaning four primary areas: Case Management, Utilization Management, Quality Management, and Reimbursement Management. We pride ourselves in our expertise in these areas, as we are able to provide our clients and candidates with an informed perspective and truly consultative approach. Visit a recent blog of ours to see how specialized and focused we maintain our recruiting efforts. However, while we are definitively more knowledgeable than other generalized staffing firms and recruiting agencies, we do not physically perform these tasks nor do we directly oversee these departments, so we need your help.

CareNational specializes in the Medical Management segment of healthcare, meaning four primary areas: Case Management, Utilization Management, Quality Management, and Reimbursement Management. We pride ourselves in our expertise in these areas, as we are able to provide our clients and candidates with an informed perspective and truly consultative approach. Visit a recent blog of ours to see how specialized and focused we maintain our recruiting efforts. However, while we are definitively more knowledgeable than other generalized staffing firms and recruiting agencies, we do not physically perform these tasks nor do we directly oversee these departments, so we need your help.

In Shakespeare’s Romeo & Juliet (Act II, Scene II) Juliet famously asks Romeo: “What’s in a name? That which we call a rose by any other name would smell as sweet.”

Operating coast to coast, and working with various types of both payer and provider organizations, we have encountered a plethora of different terminology and titles for what are essentially comparable departments, functions, and individual roles. Some, such as ‘Licensed Vocational Nurse’ vs ‘Licensed Practical Nurse’ vary state to state, while other terms, such as ‘Medical Management’ vs ‘Healthcare Services’, seem to vary based on organizational preferences. We wanted to look at each of our 4 niche segments and discuss the various titles, terms, and subsets of the discipline to see what you, the reader, had encountered in your education and experience.

A few weeks ago we addressed our first core focus area in a blog about Case Management, and we appreciate all the great feedback! This week I wanted to address the closely related field of Utilization Management. They are so closely related, with a strong understanding of one basically required in order to perform the other correctly, that there is often a lot of cross over between the roles and departments. Depending on the size and structure of the organization, you might find Care Management and Utilization Management functions under the same department; sometimes it is in the Case Management Department, less frequently it falls under Quality Management. Occasionally it will be a combination function position, where it is the same person doing both CM and UM. Here we will focus on the different titles, terms, and functional roles that fall under the Utilization Management umbrella, regardless of how it looks on an organizational chart.

“Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called ‘Utilization Review’.”
– URAC (Utilization Review Accreditation Commission) Definition of Utilization Management

Healthcare professionals involved in the Utilization Management process have the responsibility of balancing quality, risk, and cost concerns. The goal of UM is to maintain the quality and efficiency of healthcare delivery by treating patients at the appropriate level of care, coordinating all available healthcare benefits, and ensuring the least costly but most effective treatment plan. This is chiefly accomplished by validating true medical necessity using nationally accepted clinical practice guidelines, such as InterQual or Milliman standards.

Imagine going to the ER for a broken leg and the doctor orders a chest X-ray and a blood panel to check your cholesterol levels. The Utilization Review nurse at the hospital should flag that request (if no one else catches it) as lacking in medical necessity. If the hospital somehow does not catch the error, they can be sure the health insurance company will, and the claim for reimbursement will be denied. Now if that same ER doctor had ordered a leg X-ray and crutches, the Utilization Management personnel at every step would have approved the process and authorized the claim, based on established guidelines. The decades-long trend of deliberately or mistakenly ordering unneeded tests and procedures has been identified as one of the key factors in the extreme rise in healthcare costs in America, and Utilization Review nurses are on the front lines of this struggle.

For Utilization Review professionals, the various job titles and functional terms relate to when the action is taken in the patient’s continuum of care. Meaning at what stage was the treatment reviewed for medical necessity; either before, during, or after it was provided. When then review is conducted AFTER the treatment has been provided, it is called Retrospective Review, as it looks back at the usage. This is one of the most common forms of review for health insurance companies, particularly for emergency procedures where treatment cannot wait for prior health plan approval.

When the review happens DURING patient treatment, it is called Concurrent Review. These happen during active management of a condition, be it inpatient or ongoing outpatient care. The focus of Concurrent Review is to ensure that the patient is getting the right care in a timely and cost-effective way. In a health plan setting, this is a more fast-paced and demanding role requiring experienced and high-energy nurses due to the need for rapid processing of cases. Because Concurrent Review is used to decrease the amount of time you spend in the hospital, the first Concurrent Review in the hospital often determines a discharge plan.

One of the best known forms of Utilization Review occurs BEFORE the patient treatment is even scheduled, and it could be called Prospective Review but is better known as Prior-Authorization or Precertification. These might include non-emergency hospitalizations, outpatient surgery, skilled nursing and rehabilitation services, home care services, and some durable medical equipment. These treatments are typically not urgent or emergency matters and can wait the time needed for both provider and payer to play it safe and be on common terms of what will be authorized for reimbursement.

We could add more confusion and continue to muddy the waters by discussing what happens when a claim is denied and a member files an appeal on the case, or a grievance against the health plan. Since it is the Utilization Review process which initiates the process by issuing a denial of the claim, they do have a hand in denials and appeals, but most commonly appeals and grievance issues are handled by the Quality Management department. That will be discussed in detail in the next “What’s in a Name” segment, focusing on Quality Management and Quality Improvement.

As stated initially, CareNational specializes in recruitment and career search consultation in these specialized areas, but we do not perform these functions ourselves. So how did we do? Did we accurately identify the most common job titles related to these functions and duties? Did we miss anything or get anything wrong? Please let us know! What titles does your organization use? What terms have you seen throughout your career? We want to hear from the experts: that’s you!

Please comment below with your thoughts and experiences. Or contact us via email at info@carenational.com or call us toll free at 800-974-4828.