Utilization Management (UM) is an organization-wide, interdisciplinary approach to balancing quality, risk, and cost concerns in the provision of patient care (Kongstevdt, 2001). It is the process of evaluating the medical necessity, appropriateness, and efficiency of health care services. Utilization management describes proactive procedures, discharge planning, concurrent planning, precertification, and clinical case appeals. It also covers processes, such as concurrent clinical reviews and appeals introduced by the provider, payer, or patient.
The goal of UM is to maintain the quality and efficiency of health care delivery by caring for patients at the appropriate level of care, by coordinating health care benefits, ensuring the least costly but most effective treatment benefit and the presence of medical necessity. This goal is accomplished with the use of nationally accepted clinical practice guidelines.
The purpose of UM within the MTF is to identify, monitor, evaluate, and resolve issues that may result in inefficient delivery of care or that may have an impact on resources, services, and patient outcomes.. UM in the MTF is accomplished through proactive data analysis, utilization review, case management, and referral management.