Talk:Utilization management

Proposed merge with Utilization review

I'd like to suggest that the article on Utilization review be merged with this one. Both articles are dealing with the same basic topic - the Utilization review article even starts with the sentence "Utilization review is most commonly known as Utilization Management." That article has the most content (though it isn't sourced), while this one has the more appropriate name if we're going to talk about the entire process. It seems to me that we should bring over the text from the Utilization review article and put it in this one, then re-direct Utilization management to this article on Utilization management. If no one objects, I'd be glad to take a stab at it. EastTN (talk) 14:06, 30 April 2008 (UTC)

I do agree and second this proposal. —Preceding unsigned comment added by 72.187.121.86 (talk) 05:18, 27 February 2010 (UTC)

I found 885,000 matches on Google on the term "Utilization review nurse." 7,320,000 results for "Utilization review" 1,830,000 matches for "Utilization management." These numbers are all substantial. My ERISA articles on CIGNA and Aetna et. al. are riddled with the term "Utilization review," and this is because this was the term used in the case and the proceedings. Utilization management just doesn't carry the same connotation, especially with respect to this Supreme Court ruling. I agree there are similarities, but because of the number of references I have to this term I really need to have a page that defines it without ambiguity. This case is complicated enough to describe without having ambiguity in a fundamental term such as this. I am sure I can find a suitable definition in the 7,320,000 matches on internet search. MarySteinborn (talk) 17:52, 2 May 2012 (UTC)

I don't agree that UR and UM are synonymous. A utilization review is in my view a specific action performed (mostly by a UM Reviewer who is an RN) as part of a UM program. The UM program determines who does reviews, how often, and according to which criteria set. For example, the UM program may stipulate that a review is carried out in 90% of cases on each day of inpatient care, and be done using the McKesson InterQual UM criteria. UM is the organizing framework within which roles, reviews, and criteria are determined. As such, the UR is a subset of UM, not the same thing. Thanks.71.218.215.81 (talk) 15:11, 8 August 2014 (UTC)

Added text iro case management after discussion with UM program director Mloxton (talk) 19:58, 2 September 2015 (UTC)

Not so keen to redo just to fit new format rules. Will get to it at some point when I have new content to add § Mloxton —Preceding undated comment added 21:33, 20 February 2018 (UTC)

"four basic techniques in utilization management"

I haven't found any references for this text, and although the items in the list look fair enough, only Utilization Review and Case Management really look like they fit snugly under UM. Demand Management would maybe sit better under flow management as a broader topic than UM, and Disease Management seems to be a bit outside UM and fit better with clinical care, epidemiology, etc.Mloxton (talk) 21:33, 12 August 2014 (UTC)

Deleted the section since I have still not found anything to support them as recognized "techniques" of UM.Mloxton (talk) 18:23, 19 January 2015 (UTC)

Vendors versus inhouse

IIRC about half of employees insured in the United States are in ERISA plans were employers retain the risk and hire out vendors to manage the claims, which in large part involves utilization review. I think mostly big insurers do that but there's some other vendors - I think Qualis Health in Seattle was one (now Comagine Health). Would like to document the major players but haven't seen a good source discussing it. II | (t - c) 21:30, 18 May 2019 (UTC)

I added some stuff about independent review which helps to fill this gap a bit. II | (t - c) 02:03, 19 May 2019 (UTC)

Lawsuits

Denied appeals are rare, and lawsuits are even more rare. Would be good to get more information about them, but the law as of 2019 regarding ERISA plans (and probably applying similar to insured plans) is covered in relative detail by Lisa S. Kantor in Using ERISA to end proton therapy denials; legal opinions are primary sources but help give some background - see for example Woodruff v. Blue Cross and Blue Shield of Alabama et al denying coverage for proton beam therapy.

Insurers have some incentives to deny claims and thus are subject to insurance bad faith claims, but the only case I'm aware of where that happened for this type of denial was Cunningham v. Aetna, CJ-2015-2826 where Aetna got hit with a $25m penalty. There's also MetLife v. Glenn at SCOTUS. According to What should worry all insurers? First-party bad-faith lawsuits, bad faith risk has become less of a problem for ACA plans, since companies will generally follow along with the findings of the independent medical review - altho as in Woodruff mentioned above, those reviews don't necessarily come down in favor of the policyholder, which may make the lawsuit tougher. II | (t - c) 02:03, 19 May 2019 (UTC)

• This website https://www.lawyersandsettlements.com seems good for learning about disputes that reach court - see particularly insurance section. II | (t - c) 23:47, 23 July 2019 (UTC)

UM Focus

The intro paragraphs seem to emphasize cost-based prospective review above all other forms. The VA, Keiser, and other fully-capitated providers, as well as several non-profit hospitals use UM in concurrent and retrospective modes as well as prospective. It is also true for them that cost is only one aspect, and that the "medical appropriateness" criterion can as easily result in higher costs as lower, and that it has more to do with putting the patient at the *appropriate* level of care than cost avoidance. Retrospective UM is certainly more related to cost than prospective or concurrent, but even there, a patient can be referred to a higher level of care for a subsequent encounter.

Anyone else have thoughts on this? Mloxton 4.79.177.202 (talk) 18:41, 11 October 2024 (UTC)