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Monday, March 11, 2013
  Clinical Accuracy Spoken Here  

UM: Managing for Value

The goal of utilization management (UM) is to decrease the patient's length of stay (LOS) while simultaneously providing optimum quality patient care. UM brings patient-level and system-level concerns together which creates a win-win situation.

The hospital case manager (HCM) is charged with "managing for value." This means delivering high-quality care, service and outcomes cost efficiently.

[Reference: UM, Module B, Payers, Contracting and UM]

  Excellence in Case Mgmt  

UM Determines Needed Actions

The UR process practiced in most hospitals is a compulsory obligation under the terms of insurance contracts. It is also compulsory under CMS through the Conditions of Participation (CoP) for patients covered under Medicare and Medicaid. A clear distinction is drawn between the UR mandated by the payors and the UR as expressed by regulatory agencies.

Each type of review utilizes specific criteria to determine the need for further:

  • Action
  • Decision
  • Intervention

[Reference: UM, Module A, Standards and Requirements]

  Improving Patient Care...  

UM Influences Quality

The HCM tracks the activities of the team and advocates for the patient in an effort to promote appropriate, efficient, quality, cost-effective care

At the same time the HCM monitors for over-utilization/under-utilization of resources (duplication of tests, timely results).

By being informed of patient progress toward goals the team members can make timely decisions pertaining to the appropriateness of care and change interventions and treatments to more effective ones based on the clinical status of the patient supported by objective data (results of tests and procedures).

[Reference: UM, Module C, Quality of Care and UM]


Tom RasmussenTom Rasmussen
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