Utilization Management

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Definition - What does Utilization Management mean?

Utilization management is a system used to monitor the use of healthcare resources through proactive evaluation and allocation. Utilization management differs from utilization review in its proactive nature. A utilization management system will take into account available medical care resources including staff, facilities, and infrastructure. An active utilization management system will include steps such as concurrent treatment planning, discharge planning, treatment pre-certifications or authorizations, and clinical case appeals. Most utilization management system rely heavily on data to guide the decision-making processes.

SureHire explains Utilization Management

Utilization management has developed as a means for health care providers and health insurers to control the costs of patient care. By evaluating patient treatment plans on a case-by-case basis, organizations employing utilization management hope to influence the patient-care decision making process and avoid unnecessary, duplicated, or inappropriate treatments. Patient management or utilization management may be included as part of an employer-sponsored healthcare plan.

An insurer's utilization management system may require a review of proposed surgical options prior to authorizing treatment, or may recommend a set of protocols for treating specific conditions. In some instances, a patient may be assigned to a case manager who oversees each step in a treatment plan to ensure that healthcare services are being delivered efficiently.

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