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Utilization Management (UM) Managed care emanates from the basic concept of monitoring and controlling the utilization of medical services by a team approach. In simple economic terms, total healthcare costs result from 2 variables: price and volume. As discussed previously, capitation, reimbursements of providers, bundled payments, etc, describe price concept, whereas volume mainly speaks about medical services utilization. In the organizational context, utilization management is interchangeable with utilization review (UR). Shi & Singh (215) define utilization review as "evaluating the appropriateness of services provided." UR can be used in various healthcare sectors depending on the services provided. For instance, Drug UR practices address the utilization and cost of prescription drugs. UM or UR broadly divides into 3 categories: 1) Prospective, or before the event occurs; 2) Concurrent, or while the event is occurring; 3) Retrospective, or after the event has occurred; and all these reviews serve to identify cases for case management intervention, where cases with chronic illness with multiple complications or catastrophic events requires larger expenses and result in substantial costs.[18][19][20] Prospective Utilization Review: This concept applies to major categories such as health risk appraisals, demand management, referral, and institutional services. A classic example is the advanced Medicare HMO. A managed care organization intervenes in cases where patients or members require extra services to lower overall costs. For instance, when a new member joins the plan, in addition to data-gathering forms, patient history, and physical exams, a nurse is sent to home aid to check nutritional assessment, prescribed medications, and other simple interventions such as providing bathmat to prevent falls for older patients and save costs of care later in their treatment.

Prospective Utilization Review: This concept applies to major categories such as health risk appraisals, demand management, referral, and institutional services. A classic example is the advanced Medicare HMO. A managed care organization intervenes in cases where patients or members require extra services to lower overall costs. For instance, when a new member joins the plan, in addition to data-gathering forms, patient history, and physical exams, a nurse is sent to home aid to check nutritional assessment, prescribed medications, and other simple interventions such as providing bathmat to prevent falls for older patients and save costs of care later in their treatment. Concurrent Utilization Review: This review solely referred to inpatient care and case management, where continuous review is necessary, such as in inpatient cases. Assignment and tracking of the length of stay (LOS), review and rounding by UR nurses, and discharge planning are commonly used techniques for concurrent review. For example, suppose the patient is admitted with a hip fracture. In that case, the on-site UM nurse should gather information and plan discharge accordingly to the home with subsequent home health services and the need for durable medical equipment (DME) or skilled nursing facilities (SNF). In a nutshell, UM/UR nurse plays a key role in gathering information and coordinating medical services to the patient from admission to discharge while complying with the LOS guidelines to help in cost savings and generate revenue for the hospital. Retrospective Utilization Review: This review refers to the quality of care at the right time and place and billing errors. MCOs usually intervene in regularly reviewing providers to see any patterns of over or under-utilization of medical services or providers continuously making errors in the care plan and testing. MCOs usually provide physician performance data to individual physicians to compare their performance with peers. That feedback would help them modify their practices as appropriate to help curtail overall healthcare costs and improve the quality of care.

Case Management The widely accepted definition of case management by accrediting bodies such as Case Manager Certification (CCMC) is "A collaborative process which evaluates, plans, implements, coordinates, monitors, and assesses the options and services required to meet an individual's health needs, using communication and available resources to promote quality, cost-effective outcomes." The central concept of case management is that all cases do not require a continuum of care or have a high demand for medical services. Only a small portion of patients were chronically ill and needed continuous monitoring and care coordination, but they utilized the most services, resulting in considerable healthcare costs. The care management team's key role is to identify and track those complex cases, which usually slip through the cracks in the healthcare delivery system because of the requirement of care from various departments and different levels of care. High frequency of admissions in a short period and longer LOS after surgical hospitalization with multiple complications are a few examples where case managers need to be competent in clinical knowledge and play a key role in curtailing the costs of utilizing expensive medical services. Some examples of complex cases include preterm delivery, a CVA suffered by a teenager, a spinal cord injury, etc.[21]