The role of utilization management under PPS.
Under PPS an effective utilization management system is essential and the implementation of such systems presents a new challenge for hospital managers. An effective utilization management system must have the following characteristics: a process for establishing expected resource levels for each DRG; the ability to assign a working DRG at admission; a review schedule for each DRG; a method of identifying consistent patterns of high utilization; a focused review plan which targets selected DRG and physicians; a method of predicting the clinical treatment requirements of each patient; a review process which evaluates the need for continued hospitalization and identifies the reasons for any misutilization, and a feedback process which modifies the focused review plan on an ongoing basis. By operating a utilization management system with these attributes on a concurrent basis, a hospital will achieve the monitoring and control over its resources so critical under PPS. Hospitals that are able to successfully implement a utilization management system will have accomplished one of the essential components necessary to respond to PPS.
D000720:Ancillary Services, Hospital / Q000706:statistics & numerical data; D003953:Diagnosis-Related Groups; D004526:Efficiency; D006296:Health Services; D006300:Health Services Misuse; D006761:Hospitals / Q000706:statistics & numerical data*; D006801:Humans; D007902:Length of Stay / Q000191:economics; D011445:Prospective Payment System / Q000191:economics*; D012051:Reimbursement Mechanisms / Q000191:economics*; D014481:United States; D014600:Utilization Review