Utilization Management Manual

This process has several elements, including the allocation of resources, organizational structure, and control of resource consumption. The allocation of resources is typically done on a prospective basis, using actuarial analysis and historical experience to distribute resources. The organizational structure that sets standards of care and manages the resource allocation process is a key element of the resource management process. This structure often takes the form of work groups that develop standards and criteria for resource allocation. These work groups review the results of the resource management efforts and refine the standards and criteria over time, leading to improvements in medical practice and resource allocation. The control of resource consumption is another critical element of the resource management process, typically referred to as utilization management or utilization review. This process involves approving referrals for specialized or inpatient care and determining the most appropriate course of care. The goal of utilization management is to ensure that the expenditure of resources is both clinically and financially appropriate. The information system (MIS) plays a crucial role in tracking the use of resources on a regular and structured basis. The MIS should track the actual versus expected consumption of resources, and the results of the resource consumption analysis should be used to develop budget assumptions for subsequent periods, analyze the results for specific groups of providers, manage risk and incentive pools, and identify areas where one or more work groups should focus their efforts to redefine the critical paths necessary to provide quality, cost-effective care. The resource management process is an iterative process that should be in constant motion, with a focus on the results of care rather than the resource management process itself. Good results will foster good management of resources. This handbook provides a collection of tools that individual provider networks and systems can pick and choose from to assist them in managing their resources. Developing a resource budget is a critical aspect of the resource management process. Most modern managed health care organizations use a system of global budgeting, setting a budget based on per capita costs or revenue rather than line-items. The per-capital budget can be subdivided by sub-organization unit, known as decentralization of budget responsibility. This approach allows management flexibility in re-programming funds based on unexpected changes in volume. There are two primary methods for developing a global budget: historical and actuarial. The historical method relies on past experience without critical evaluation, which can lead to compounded errors in resource allocation. The actuarial method takes historical data and makes adjustments to account for changing demographics, benefit packages, and improvements in medical procedures. This approach is more accurate and flexible than the historical method. The actuarial method involves several steps, including data collection, data analysis, and budget development. The data collection process involves gathering information on past resource utilization, including the types and quantities of services provided. The data analysis process involves analyzing the data to identify trends and patterns in resource utilization. The budget development process involves using the analyzed data to develop a budget that takes into account the expected resource utilization and the available resources. In addition to the historical and actuarial methods, there are other approaches to developing a global budget, including the use of management information systems (MIS) and the development of a resource management plan. The MIS can provide valuable insights into resource utilization and help identify areas where resources can be optimized. The resource management plan can provide a framework for managing resources and ensuring that they are used efficiently and effectively. Overall, developing a resource budget is a critical aspect of the resource management process, and there are several approaches that can be used to develop a global budget. The choice of approach will depend on the specific needs and circumstances of the organization, and it is essential to select an approach that is accurate, flexible, and effective in managing resources.