Potential Conflicts Associated with Utilization Management and Quality Improvement in Home Care

Abstract

A transition from utilization review to utilization management and quality improvement (UM/QI) is occurring in home health care today. Prior authorization of payment by managed care companies for services delivered by providers is an area of concern. Questions arise regarding service delivery, payment, and patient need. Health care reform calls for agencies to take a closer look at their utilization patterns regardless of the payment source. Services delivered must match patient need for care if the outcomes are to be of high quality and the care cost effective. The UM/QI specialist must be aware of the expectations and requirements of managed care companies, federal and state regulatory agencies, accrediting bodies, and, ultimately, the patients whom they serve. This article discusses the potential conflicts faced by providers and the role of the UM/QI specialist in home health care today.

Keywords

quality improvement utilization management utilization review

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