UTILIZATION MANAGEMENT
NURSE EXAM 2023\2024
, 1.Utilization - CORRECT ANSWERS-How efficient a facility is in providing
necessary care in the most cost-effective manner
Goal of Utilization Review - CORRECT ANSWERS-1. To prevent overutilization
or underutilization of resources
2. To control inappropriate use of health resources
Overutilization - CORRECT ANSWERS-1. Using to many unnecessary
resources
2. Not needed for that diagnosis or treatment
Example; using the ER for runny nose
Underutilization - CORRECT ANSWERS-1. Hospital resources not used when
they were necessary
Example: Discharge a patient too soon or not giving patient adequate tests
or readmission to hospital
Medical Necessity - CORRECT ANSWERS-Is or Was the treatment medically
necessary and appropriate for that patient
- Tests
- Surgical Procedures
- Ancillary Services
Utilization Review - CORRECT ANSWERS-1. UR evaluates the level of care
needed
2. First became mandatory in 1965 with Medicare.
3. First Attempt at UR - PSRO - Failed
- 1972 Professional Standards Review Organization (PSRO) Had no Teeth
authority) and could not enforce standards they could only suggest things
NURSE EXAM 2023\2024
, 1.Utilization - CORRECT ANSWERS-How efficient a facility is in providing
necessary care in the most cost-effective manner
Goal of Utilization Review - CORRECT ANSWERS-1. To prevent overutilization
or underutilization of resources
2. To control inappropriate use of health resources
Overutilization - CORRECT ANSWERS-1. Using to many unnecessary
resources
2. Not needed for that diagnosis or treatment
Example; using the ER for runny nose
Underutilization - CORRECT ANSWERS-1. Hospital resources not used when
they were necessary
Example: Discharge a patient too soon or not giving patient adequate tests
or readmission to hospital
Medical Necessity - CORRECT ANSWERS-Is or Was the treatment medically
necessary and appropriate for that patient
- Tests
- Surgical Procedures
- Ancillary Services
Utilization Review - CORRECT ANSWERS-1. UR evaluates the level of care
needed
2. First became mandatory in 1965 with Medicare.
3. First Attempt at UR - PSRO - Failed
- 1972 Professional Standards Review Organization (PSRO) Had no Teeth
authority) and could not enforce standards they could only suggest things
