Florida Health Insurance Terms:
"Utilization Management (UM)"

Define: "Utilization Management"

Utilization Management, or (UM) is a management tool used by managed care plans involving the systematic process of reviewing and controlling patients' use of medical services and providers' use of medical resources in order to optimize efficiency and appropriateness of care. UM includes an array of techniques, such as second surgical opinion, preadmission certification, concurrent review, case management, discharge planning, and retrospective chart review.

ALSO: Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case.

Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.

More Examples of Utilization Management

"Almost every provider or payer sponsored utilization management program includes preadmission and concurrent review." Typical characteristics of these two components are:

• Collection of data about diagnosis, required services, diagnostic test results, and symptoms
• Review of criteria that describe the conditions or services to support the care request
• Comparison of medical information to medical necessity criteria
• Referral of case to physician review if criteria are not met
• Physician determination of medical necessity
• Communication of review outcome
• Right of physician to appeal decision

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