Healthcare Utilization Management Explained

Healthcare Utilization Management

Utilization management is one of the unique healthcare services designed for the benefit of the patients. It helps to keep a systematic update of the followed procedures, so that patients can have a seamless experience.

With rising healthcare costs in US, it has become a necessity to have the right utilization of the resources. A good management solution leading to a streamlined service is what utilization management means in health care service.

It is a crucial part of the health care service, and there are different procedures followed in it:

  • Retrospective review

    This is a form of medical records review that is conducted after the discharge of the patient. The review tracks the record, whether proper health care service was provided to the patients, whether there was the right consumption of resources and appropriateness of the care. How effective was resource utilization and what all resources where utilized, are some of the crucial aspects which retrospective review keeps a complete track throughout the process.

  • Prospective review

    Before patient admission, there has to be a review of medical necessity for checking the performance. As patient care is of utmost importance, it has to be checked whether all the procedures required in the treatment process of the patient are diligently followed.

  • Concurrent review

    It includes the decision-making process to be followed when the patient is nearing the post-acute setting or is at an acute condition. The post-acute setting is a growing health care service, where some of the patients, after recovering from traumatic conditions, such as accidents, severe depression need the right medical care. The review keeps track of their condition for the right decision later to be followed.

  • Preadmission certification

    When the patient goes for admission, authorization has to be granted so that he can be admitted to the hospital for the health care service. In all the cases, it is seen that the specific requirements have to be fulfilled for admitting the patient.

The utilization management process includes:

  • In this process, the complete information of the member has to be collected. This includes the entire condition of the patient, and all depends on the information which needs to be accessed. It can include the progress of the patient, radiology, test results, and other forms of treatment.
  • In the second step, the review has to be executed to understand the medical necessity of the specific services.
  • Here all the parties who are involved in the utilization management are notified, thus improving the review process.

To make the process effective, utilization management has different programs:

  • Step therapy

    It helps to lower the costs through the less expensive and safe drugs. The process ensures that the patients are having the right access to the drugs. For the experimental purpose, they have to first try the safe drug after which they can try the different drug.

  • Prior authorization

    With the availability of various drugs in the market, it has been seen that there are specific drugs that are misused or overused leading to harmful health conditions of the patient. To stop this alarming situation, the authorization process makes it mandatory for the approval of all the medicines by the health plan.

  • Quantity limits

    There has to be a specific procedure for checking the quantity of medicine to be used. This helps the patient in understanding how much amount and the frequency of the medicine which needs to be used. The process encourages the safe usage of the drug, and reduces the waste.


With the increasing population, health care service has become a necessity. Utilization management refines this service with the best possible procedures, so that the patient receives good experience during the treatment and even after the treatment.