Utilization management (UM) has become a strong trend in health care cost containment. Under UM, some decisions are not strictly made by the doctor and patient alone. Instead, they are now checked by a reviewer reporting to an employer or other paying party who asks whether or not the proposed type or location of care is medically necessary or appropriate.

This book presents current findings about how UM is faring in practice and how it compares with other cost containment approaches, with recommendations for improving UM program administration and clinical protocols and for conducting further research.

• Front ... Read moreMatter
• Executive Summary
• Utilization Management: Introduction and Definitions
• Origins of Utilization Management
• The Utilization Management Industry: Structure and Process
• Impact of Prior Review Programs
• High-Cost Case Management
• Conclusions and Recommendations
• Acknowledgments
• Appendixes
• Appendix A - Legal Implications of Utilization Review
• Appendix B - Utilization Management and Quality Assurance in Health Maintenence Organiztions: An Operational Assesment
• Appendix C - Utilization Management in Peer Review Organizations
• Appendix D - Summary of Public Hearings
• Appendix E - Summaries of Committee Site Visits to Utilization Management Organizations
• Appendix F - Analysis of Agreements Between Utilization Management Organizations and Their Clients
• Appendix G - Glossary and Acronyms
• Appendix H - Biographies of Committee Members
• Index