The heart of the cost-management business is contracting with employers for "utilization management" services.

Financial incentives based on utilization management were changed to those based on quality measures.

There are four basic techniques in utilization management:

Medicare plans "may subject these drugs to utilization management" techniques, widely used by insurers and pharmacy benefit managers, the government said.

Instances of inappropriate utilization management on behalf of managed-care entities do exist.

Inappropriate utilization management exists in greater number in fee-for-service medicine, where the incentives are to provide more services than necessary.

These techniques, which are gaining popularity in the workers' compensation area, include utilization management, preferred provider organizations and aggressive auditing of medical bills.

To managed-care companies, these sentries, known at HealthNet as utilization management coordinators, are the first line of defense against unnecessary care.

Other managed care techniques include disease management, case management, wellness incentives, patient education, utilization management and utilization review.

Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals.

Mr. Herbert is too quick to condemn the utilization management policies of Prudential HealthCare.

As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review.

The difference is utilization management is prospective and intends to manage health care cases efficiently and cost effectively before and during health care administration.

They are comprehensive utilization management systems, which are designed to generate various managerial reports, aggregate patient data, track patients, and promote accurate scoring and ease of use.

His professional and academic research interests have focused on clinical laboratory automation including robotics, information systems, medical utilization management, business efficiency modeling, telehealth, telemedicine and mobile health.

Mary Ellen O'Donnell, director of utilization management with the national Blue Cross and Blue Shield Association in Chicago, said a number of Blue Cross plans use sophisticated programs.

Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan.

The additional cost would be partially offset by: a) incremental "utilization management" or care restrictions exerted by private providers versus Medicare; and b) enrollees facing increased cost-sharing would tend to lower utilization of services.

Prompt Pay Regulations: The memorandum clarifies that compliance with clean claims regulations does not prevent sponsors from establishing drug utilization management and quality assurance programs to prevent overutilization that are required under existing regulations.

"The well-defined utilization review process does not reduce care by creating barriers to care," said Nazie Eftekhari, chairman of the Midwest division of the Ethix Corporation, which does utilization management for many insurance companies.

ARUP's suite of Utilization Management Services is a comprehensive approach designed to unite the development of outreach and connectivity with the appropriate ordering and utilization of laboratory tests according to medically relevant criteria.

In February 2013, IBM announced that Watson's first commercial application would be for utilization management decisions in lung cancer treatment at Memorial Sloan-Kettering Cancer Center in conjunction with health insurance company WellPoint.

WHN developed both a Care Management/Utilization Management Department to review and authorize requests for services and a Care Coordination Department to provide the administrative function of treatment planning for a select high needs/high risk population.

At the hospital where I work, a referral center for seven counties, nurses are now the chief executive officer and president, vice president of patient services, director of utilization management, assistant director of patient financial services, director of surgery and quality assurance coordinator.

On the other hand, it is still generally acceptable in the American medical community to remove a gall bladder from a patient with gallstones even if discomfort is minimal and is not clearly caused by the stones, said Mary Ellen O'Donnell, director of utilization management at the Blue Cross and Blue Shield Association.

Sometimes patients can place a call themselves to the utilization review firm to try to get more data about their case.

How to use an article about a clinical utilization review.

While utilization review companies operate in different ways, there are two basic types.

"The process, sometimes known as 'utilization review,' has had a bad name among physicians," he added.

For their part, the utilization review companies are writing industry standards, one of which would protect confidential records.

He said that "utilization review" software is already used in other fields of medicine.

Medicare and Medicaid have employed utilization review techniques for a number of years.

The good news, widely reported in the media, is that utilization review does save money without apparent impairment of quality.

But even if utilization review can eliminate all unnecessary admissions and days, it won't have much impact on hospital costs over the long term.

This determination may be made either prior to or after hospital admission (concurrent utilization review).

But that number is shrinking rapidly as additional conventional plans adopt utilization review procedures.

"The overwhelming majority of patients are the subject of outside third-party utilization review or case management."

In addition, it provides the logical level at which to undertake quality assessment, audit and utilisation review activities.

The company, a utilization review company, specializes in evaluating the health care doctors recommend.

Beginning two decades ago with the idea of obtaining second opinions before surgery, utilization review has become a major factor in the nation's health-care system.

The analysis was conducted by a utilization review concern hired by three large medical insurance companies, two of which provide managed care.

The utilization review nurse couldn't understand why I had not discharged a 7-year-old boy within 36 hours of his surgery for appendicitis.

Wait until you have your utilization review.

In pursuit of a painless method for containing hospital costs, American industry now has a new white knight: utilization review.

Second-guessing doctors' decisions, formally known as utilization review, has become ubiquitous in American medicine.

The utilization review company might question the length of stay, stating that the insurance company normally pays benefits for two days.

In the late 1980s concerns grew over the lack of uniform standards for utilization review (UR) services.

Utilization review is more retrospective considering whether health care was appropriately applied after it was administered.

The software guides "utilization review" nurses in telephone conversations with prospective patients whose health plan requires prior approval.

Mr. Custer said the screening process, which insurers call utilization review, is used mainly by large companies because of its relatively high cost.