01:920:210 Lecture Notes - Lecture 23: Utilization Management, Managed Care, Health Maintenance Organization
14 Dec 2016
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Document Summary
Class 23: managed care: major features of managed care, utilization is monitored. Pre-authorization of treatment may be required: care is limited by third party. Insurance companies do the monitoring of use of the care services: what kind of care patients receive and amount of care, choice of doctor is limited, any kind of medical care, two basic kinds of managed care. External utilization review- a third-party (independent and has different goals), doc, and patient; external to the provision of care, actual treatment process. Internal utilization review- done in hmos, inside medical care facility, have a financial state in not providing too much care (over-treat) Detailed example of external ur for mental illness hospitalization (children in adolescence) Patient shows up at hospital er in crisis: unmanageable for parent dangerousness to self or others diagnosis of children. Patient presents insurance card: child is in crisis, needs help immediately unless he/she is near death, hospital calls to verify insurance.
