Case Management Chapter 4: Utilization Management

Question 1

Utilization Review

Answer 1

Process in which medical review determinations are made based on clinical guidelines and structured processes.

Question 2

Utilization Management

Answer 2

Evaluation of of medical necessity, appropriateness, and efficiency of the use of healthcare services, procedures, and facilities under the auspices of the applicable health benefit plan.

Question 3

Common reasons for denials

Answer 3

information not shared within reasonable or requested time frame; procedures performed in wrong level of care/setting; weekend-related lack of services resulting in longer stay; services not covered by health plan; untimely billing; lack of prior auth; clinical condition not requiring inpatient stay; condition not meeting inpatient admission criteria.

Question 4

Lag days

Answer 4

Inappropriate acute inpatient days; may result in denial; good case management avoids these.

Question 5

Causes of variances that may lead to lag days

Answer 5

patient/family reasons, practitioner reasons, institution/systems reasons, community reasons.

Question 6

InterQual’s criteria (I-S-D)

Answer 6

Intensity (of service) Severity (of illness) Discharge screens (how stable patient is for discharge

Question 7

MCG

Answer 7

Based on diagnoses or diseases; unlike InterQual, which are written based on body systems.