Case Management Center
Utilization management broadly refers to services designed to evaluate the necessity, appropriateness, and efficiency of the use of medical services. It also includes advocacy and facilitating access to care. These services are provided in many settings, including insurance companies, hospitals, and managed care organizations. Goals include optimizing effective use of payer funds for services, maximizing timely reimbursement to health care providers, and evaluating variations in service delivery that impact the costs of care.
At Boston Children's Hospital, the utilization management case managers perform many functions. They assist with preadmission approvals for services that will be provided at our hospital. They review medical record reviews for our hospitalized patients in order to ensure continued approval for inpatient services. Likewise, they perform retrospective reviews and appeals of insurance denials for services that have already been provided by Children's Hospital clinicians.
In the sections that follow, we have included information regarding utization management in today's health care delivery system.