The Hospital Guide to Contemporary Utilization Review is a comprehensive resource designed to identify utilization review (UR) best practices and provide guidance on developing and enhancing a contemporary UR committee. This book focuses on the latest UR and patient status requirements to help hospitals perform high-quality reviews and comply with regulations. The book covers a range of topics, including compliance with the UR Condition of Participation, legal obligations of a hospital, contract language, and compliant UR plan language to provide an understanding of the expectations of a UR program. Tips for intradepartmental collaboration are included to guide professionals through the process of selecting a physician advisor and partnering with nurses, case managers, and revenue cycle team members. This book will help you do the following: Identify the components of a best practice hospital utilization review (UR) program Describe the legal obligations of the hospital to comply with chapter 42 CFR 482.30 of the Conditions of Participation (CoP) Use the publication as a tool to assess his or her own hospital's UR processes Summarize the benefits of a dedicated UR team to promote compliance with the CoP Facilitate the development of a contemporary UR committee Assess an organization's opportunities to improve processes to benefit patient care and hospital success Recommend compliant language for the organization's UR plan Construct commercial contract language, in collaboration with the organization's contract manager, that promotes a partnership to ensure appropriate use of acute care resources Seek out operational resources to perform high-quality reviews that fully comply with the CoP Explain the connection between a good utilization review plan and the hospital revenue cycle initiatives

Utilization management (UM) has become a strong trend in health care cost containment. Under UM, some decisions are not strictly made by the doctor and patient alone. Instead, they are now checked by a reviewer reporting to an employer or other paying party who asks whether or not the proposed type or location of care is medically necessary or appropriate. This book presents current findings about how UM is faring in practice and how it compares with other cost containment approaches, with recommendations for improving UM program administration and clinical protocols and for conducting further research.

This book is the first comprehensive text on utilization management in the clinical laboratory and other ancillary services. It provides a detailed overview on how to establish a successful utilization management program, focusing on such issues as leadership, governance, informatics, and application of utilization management tools. The volume also describes ways to establish utilization management programs for multiple specialties, including anatomic pathology and cytology, hematology, radiology, clinical chemistry, and genetic testing among other specialties. Numerous examples of specific utilization management initiatives are also described that can be imported to other heath care organizations. A chapter on utilization management in Canada is also included. Edited by an established national leader in utilization management, Utilization Management in the Clinical Laboratory and Other Ancillary Services is a valuable resource for physicians, pathologists, laboratory directors, hospital administrators, and medical insurance professionals looking to implement a utilization management program.

The second edition of Patton's classic text retains the practical advice, based on empirical observation and evaluation theory, of the original. It shows how to conduct an evaluation, from beginning to end, in a way that will be useful -- and actually used. Patton believes that evaluation epitomizes the challenges of producing and using information in the information age. His latest book includes new stories, new examples, new research findings, and more of Patton's evaluation humour. He adds to the original book's insights and analyses of the changes in evaluation during the past decade, including: the emergence of evaluation as a field of professional practice; articulation of standards for evaluation; a methodological synthesis of the qualitative versus quantitative debate; the tremendous growth of 'in-house' evaluations; and the cross-cultural development of evaluation as a profession. This edition also incorporates the considerable research done on utilization during the last ten years. Patton integrates diverse findings into a coherent framework which includes: articulation of utilization-focused evaluation premises; examination of the stakeholder assumption; and clarification of the meaning of utilization. --Publisher description.

Managed Care Pharmacy Practice, Second Edition offers information critical to the development and operation of a managed care pharmacy program. The text also covers the changes that have taken place within the delivery of pharmacy services, as well as the evolving role of pharmacists.

The Social Security Administration (SSA) administers two programs that provide benefits based on disability: the Social Security Disability Insurance (SSDI) program and the Supplemental Security Income (SSI) program. This report analyzes health care utilizations as they relate to impairment severity and SSA's definition of disability. Health Care Utilization as a Proxy in Disability Determination identifies types of utilizations that might be good proxies for "listing-level" severity; that is, what represents an impairment, or combination of impairments, that are severe enough to prevent a person from doing any gainful activity, regardless of age, education, or work experience.