Utilization Management

Purpose and Function

The Utilization Management Department works closely with but independent of both the Case Management & Clinical Documentation Departments. In contrast to our affiliates or other facilities where these functions/departments may be combined, it is a split model at Flint McLaren.

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Utilization Review (UR), also known as Utilization Management (UM), facilitates appropriate utilization of resources in the acute care setting enhancing both patient and organizational outcomes through:

  • Admission status review
  • Compliance with hospital admission screening criteria, third party payer guidelines and state regulations
  • Review of clinical documentation in the medical record to support medical necessity

This information is used to:

  • Determine the appropriate admission status (inpatient, observation, and extended recovery) on a case by case basis
  • Prevent the financial burden of unnecessary copays to the patient
  • Support compliant billing practices
  • Prevent payment denials to both the hospital and the physician.

Medicare/Medicaid HMO CMS Guidelines

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Third Party Payer Guidelines

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Appeals & Denials

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Surgical

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Medical

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Cardiology

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