Utilization Review
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The Utilization Review Process
Utilization review is a process practiced in hospitals and healthcare institutions towards ensuring that the existing healthcare services are being offered to the patients effectively and on a timely basis whenever needed. The utilization review process follows particular criteria meant towards ensuring its effectiveness in attaining its set objectives. The three significant activities entailed in the process include but are not limited to prospective review, concurrent and retrospective reviews (Ali-Faisal et al. 2017). The future study primarily consists of the general thought on the existing medical equipment and services available towards determining their necessity and effectiveness in performing various scheduled activities before patients’ admission. Concurrent reviews include an analysis of the medical necessity conclusions deduced by medical experts while having the patient in acute and post-acute situations. Additionally, the retrospective reviews are carried out once the treatment process has been concluded (Ali-Faisal et al. 2017). The general review process, however, entails other stuff such as medical necessity which mainly determines whether the hospital’s admission to patients is effective and justifiable (Ali-Faisal et al. 2017). The other activity includes continued stay, which serves as a determinant of whether the patients’ stay is necessary for any healthcare setting. Care levels mainly serve as a determinant of the appropriate care needed on patients.
Reasons why Utilization Review is a Positive Process
I agree that utilization review is quite a joyous process. The study offers a range of benefits in healthcare and medical settings, including but is not limited to; ensuring patient care, thus maintaining the entire individuals’ population (Bean et al. 2020). Additionally, analyzing the retrospective review’s relevant data provides an adequate evaluation of the effects associated with various treatment procedures.
Recommendations
I strongly recommend that healthcare institutions should introduce appropriate models depending on the nature of the healthcare institution. Considering the situations surrounding certain healthcare conditions will ensure the effectiveness of the results obtained after the process. Additionally, I strongly recommend that communication and collaboration processes be enhanced in the healthcare sector to ensure that medical officers are well equipped with the knowledge of the various changes occurring in the healthcare and hospital sectors (Ali-Faisal et al. 2017). Education and feedback for doctors regarding the most appropriate care standards and practices should be enacted as well.
Response: Jessica Watson
You have clearly stated the utilization review. You have also explained in detail the various steps entailed in the utilization review process. You have offered prospective, concurrent, and retrospective insights as the significant activities entail the utilization review process. You have also explained the benefits of the utilization review process, including setting the significant levels necessary for enhancing patient care in healthcare institutions.
You have given the most significant changes which should be incorporated in the review process, which I fully agree with. Ensuring effective communication will enhance coordination within the health sector and provide consistent results following the review process. Considering the hospitals’ condition before approving the review process will ensure appropriate techniques are applied to ensure the products’ accuracy.
The steps that managers should incorporate in decision-making entail; defining the existing problem in the given setting, identifying the current limiting conditions, and developing suitable potential alternatives. Additionally, the manager should analyze the given options and eventually select the best one that best suits the physician and the utilization review body. You have a good flow of ideas, and I’m impressed.
Response: Lakesha Phillips
You have agreed that utilization review is a positive process. You have explained the role of utilization review in ensuring that individuals are bound to services depending on their situations, and can receive utmost care during and after their healthcare institutions stay. You highly recommend that new and modern technologies should be introduced in hospitals. You have also suggested that the processes put in place should be altered to satisfy the patients fully. You have also indicated that utilization review majorly deals with two opposing forces; the physicians’ agenda and the gatekeepers’ agenda. You have a good flow of ideas. Your work is excellent. You have portrayed a good understanding of the subject matter under discussion.
References
Ali-Faisal, S. F., Colella, T. J., Medina-Jaudes, N., & Scott, L. B. (2017). The effectiveness of patient navigation to improve healthcare utilization outcomes: A meta-analysis of randomized controlled trials. Patient Education and Counselling, 100(3), 436-448.
https://www.mcg.com/blog/2018/06/21/utilization-review-medical-necessity/
Bean, M., Erdil, M., Blink, R., McKinney, D., & Seidner, A. (2020). Utilization Review in Workers’ Compensation: Review of Current Status and Recommendations for Future Improvement. Journal of Occupational and Environmental Medicine, 62(6), e273-e286.
https://www.verywellhealth.com/utilization-review-what-it-is-how-it-works-1738788