Clinical and fiscal outcomes of utilization review.
Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.
Murray
Mary Ellen
ME
School of Nursing, University of Wisconsin-Madison, K6/340 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA. memurra1@facstaff.wisc.edu
Darmody
Julie V
JV
D019090:Case Management / Q000458:organization & administration; D003142:Communication; D003211:Concurrent Review / Q000458:organization & administration*; D003363:Cost Control; D006302:Health Services Research; D006801:Humans; D007345:Insurance Claim Review / Q000458:organization & administration; D019458:Insurance Coverage / Q000458:organization & administration; D008329:Managed Care Programs / Q000458:organization & administration; D024802:Nurse's Role; D017063:Outcome Assessment, Health Care / Q000458:organization & administration*; D010343:Patient Admission / Q000191:economics / Q000592:standards / Q000706:statistics & numerical data; D010347:Patient Care Planning / Q000458:organization & administration; D010564:Personnel, Hospital / Q000523:psychology; D012051:Reimbursement Mechanisms / Q000458:organization & administration; D012621:Seasons; D011795:Surveys and Questionnaires; D017749:Total Quality Management / Q000458:organization & administration