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Development of an outpatient utilization review program.

Journal (American Medical Record Association)

|November 5, 1989

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Outpatient service use is increasing, driving up healthcare costs. This article explains managed care objectives and outpatient utilization review priorities for insurers and employers.

Area of Science:

Health Services Research
Healthcare Management

Background:

Outpatient service utilization has significantly increased.
Rising ambulatory care costs present challenges for insurers and employers.
Effective cost containment strategies are in demand.

Purpose of the Study:

To outline the objectives of managed care organizations.
To identify key performance indicators for outpatient utilization reviews.
To provide insights for cost-effective ambulatory care management.

Main Methods:

Literature review of managed care principles.
Analysis of common outpatient utilization review practices.
Synthesis of industry expert perspectives.

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Main Results:

Managed care aims to balance cost, quality, and access.
Utilization reviews focus on medical necessity, appropriateness, and efficiency.
Key metrics include readmission rates, procedure costs, and length of stay.

Conclusions:

Understanding managed care objectives is crucial for providers.
Strategic outpatient utilization review can mitigate rising healthcare expenditures.
Collaboration between payers and providers can optimize ambulatory care delivery.