Utilization Management

Question 1

Coordination of Benefits (COB)

Answer 1

• More than one health insurance plan.
• Prevents double payment for services when subscriber has
  coverage from 2 or more sources.
• Employee insurance plan pays first
• Medicare/Medicaid are always secondary.

Question 2

Prospective Review

Answer 2

A method of reviewing possible hospitalization before admission to determine necessity and estimated length of stay.

Question 3

Concurrent Review

Answer 3

A method of reviewing patient care and services during a hospital stay to validate the necessity of care and to explore alternatives to inpatient care. It is also a form of utilization review that tracks the consumption of resources and the progress of patients while being treated.

Question 4

Retrospective Review

Answer 4

A form of medical records review that is conducted after the patient’s discharge to track appropriateness of care and consumption of resources.

Question 5

Utilization Management Purpose

Answer 5

Ensures that services aer medically necessary, provided in the most appropriate care setting, and at or above quality standards.