Utilization Review And Quality Management Essay

1033 Words Oct 14th, 2015 5 Pages
As employers look to control health care costs, Managed Care Organizations (MCOs) have implemented utilization review protocols to ensure the right care is provided to patients at the right time. At the same time, employers, regulatory agencies and accreditation organizations have increased their expectations that the quality of care increases for patients receiving care through the MCO. This paper will provide insight into the managed care industry with specific focus on utilization review and quality management.
Utilization review and quality management are two key components in the managed care industry. Utilization review is defined by Mosby’s as “an assessment of the appropriateness and economy of an admission to a health care facility or a continued hospitalization. The length of the hospital stay also is compared with the average length of stay for similar diagnoses.” Mosby’s define quality management as “any evaluation of services provided and the results achieved as compared with accepted standards.” Managed care is dependent on utilization review to not only focus on reducing inpatient admissions and eliminating unnecessary hospital days, but also become engaged with discharge planning and transitional care such as stepdown from inpatient to outpatient services. As managed care has specific accreditation and regulatory requirements to meet, a successful quality management program needs to be in place.
There are three key elements involved when utilization review…

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