MHA540 SLP MODULE 2 UTILIZATION MANAGEMENT, UTILIZATION REVIEW, AND CASE MANAGEMENT ESSENTIALS

MHA 540 SLP Module 2 Utilization Management, Utilization Review, and Case Management Essentials Student's Name Institutional Affiliation Course Professor's Name Submission Date Part One Types of Assessment in Utilization Review Prior Authorization Ї Assess the necessity and appropriateness of medical services before providing them. Ї It is done using computerized admission criteria in settings like EDs Ї It helps control costs, improve communication, and enhance care coordination (Desai et al., 2017). Concurrent Utilization Review Ї Review occurs during patient care within a facility. Ї Monitors care type, necessity, and level/setting of care. Ї Implemented in post-acute care (PAC) phases, resulting in decreased length of stay (LOS) and optimized care delivery (El-Othmani et al., 2019). Retrospective Review Ї Assesses appropriateness and necessity of services after provision. Ї Conducted by health care managers, aims to confirm efficient and effective care delivery. Ї Leads to cost savings, improved appropriateness of testing, and informs changes in care delivery and resource utilization (Wakefield et al., 2018). Speaker Notes Prior Authorization Before delivering medical services or treatments, assess their necessity and suitability. Pre-auth controls to ensure the requested healthcare treatment or procedure is appropriate and contextual. Desai et al. (2017) showed emergency department pre-auth automated admission criteria. Prior authorization can enable healthcare organizations to communicate about individuals being examined or diagnosed with certain illnesses, improving access to treatments and patient care coordination while controlling costs. Concurrent Utilization Review While hospitalized, the patient is reviewed simultaneously. The concurrent review establishes an oversight method to examine the kind, need, level, and setting of care. In El-Othmani et al. (2019) research, the Joint Utilization Management Program used concurrent review to track the length of stay in post-acute care (PAC) for total joint arthroplasty patients. LOS decreased with time, proving contemporaneous review optimizes care delivery. Concurrent Review allows quality monitoring, access to additional services and supports, and care coordination, especially during transitions to the next appropriate level of care, such as a discharge to home or a lower-level setting. Retrospective Review After services are supplied, they are evaluated for suitability. The retrospective review ensures that care is appropriate, efficient, and effective. Genetic counselors retrospectively reviewed incoming test orders in a molecular genetics laboratory to discover inefficiencies or incorrect test ordering in Wakefield et al. (2018). This evaluation suggested test order changes that saved money and enhanced testing. Healthcare managers supervise retrospective reviews, assess results, and make adjustments to improve care delivery and resource use. Part Two Assessment in Healthcare Prior Authorization * The surgical team conducts a prospective review before elective surgery. * Ensures medical necessity and appropriateness. * Prevents unnecessary surgeries, preserves quality, and controls costs (Santos & Jones, 2023). Concurrent Utilization Review * The healthcare team monitors patient progress during rehabilitation (Dalvandi et al., 2020). * Adjusts treatment plan based on response to therapy. * Ensures timely interventions, preserves quality, and controls costs. Retrospective Utilization Review * Conducted after patient discharge. * Examines medical records to assess care appropriateness. * Identifies areas for improvement and minimizes unnecessary expenditures. Speaker Notes Prior Authorization The hospital surgical team does a prospective utilization evaluation before elective surgery is performed. They evaluate the patient's medical history, present condition, and planned operation to determine if the surgery is warranted. They also check for less-invasive procedures. The patient is scheduled for surgery if the evaluation finds it necessary. Prospective reviews prevent needless, risky procedures (Santos & Jones, 2023). Ensure patients receive the most suitable therapies to maintain quality. The evaluation process reduces unneeded operations, complications, and healthcare expenditures. Concurrent Utilization Review Concurrent utilization review is performed on stroke patients in rehabilitation. Physicians, therapists, and case managers monitor the patient's development, therapy, and...