Utilization Management Explained

Utilization Management Explained

Utilization Management is also know as managing 'Bed Days.'

When a patient with commercial health insurance is admitted to the hospital, the hospital is required to obtain approval from their health insurance company for payment.

When the health insurance company approves the hospital stay, it only does so for a certain number of days. That number of days is determined by the clinical situation of the patients.

For example, pneumonia may be approved for 3 days and a scoliosis surgery for 5 days.

Only two companies in all of America set the standard for 'Bed Days.' Those companies are Interqual and MCG Care Guidelines.

Interqual is owned by UnitedHealth Group and MCG Care Guidelines is owned by Hearst.

$400B in inpatient healthcare spending is run through Utilization Management every year making Interqual and MCG Care Guidelines VERY POWERFUL companies.

CORRECTION: The St. Louis newspaper is not owned by Hearst.

Sources:
https://www.changehealthcare.com/clinical-decision-support/interqual/level-of-care-criteria

https://www.changehealthcare.com/clinical-decision-support/interqual/level-of-care-criteria#interqual

https://www.doximity.com/pub/monique-yohanan-md

https://www.bcbsnd.com/providers/news-resources/healthcare-news/2022-interqual-criteria-implementation

https://www.mckesson.com/About-McKesson/Newsroom/Press-Releases/2017/McKesson-and-Change-Healthcare-Complete-the-Creation-of-New-Healthcare-Information-Technology-Company/

https://www.kff.org/medicare/issue-brief/traditional-medicare-spending-fell-almost-6-in-2020-as-service-use-declined-early-in-the-covid-19-pandemic/

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0481

https://www.mcg.com/care-guidelines/care-guidelines/

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