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AHA 213 - Managing Utilization and Risk
It is essential for health care facilities to be able to control and manage the use of their services to minimize the risk of financial loss. Utilization review monitors and provides appropriate incentives to influence the use of health care services. Risk management employs proactive efforts to prevent adverse events related to clinical care and facility operations especially malpractice. The proper use of utilization review and risk management measures has the potential to achieve significant containment of health care costs, an essential outcome in our present health care system.
This course explores the concepts of risk management and utilization review in payor and provider organizations.
Upon successful completion of this course, students should be able to:
- Trace the history and development of utilization review and risk management processes.
- Describe the requirements for utilization review procedures in relation to various payor organizations (managed Medicare, Medical Assistance and private insurers). Analyze the role of the physician and other health care personnel in utilization review.
- List the various mechanisms used in the utilization review process by payor and provider organizations.
- Explain the role of the health care manager in the utilization review process.
- Trace the development of legal doctrines and concepts of individual responsibility.
- Cite landmark court decisions that have increased the liability of health care institutions.
- Identify the procedures used for documenting and reporting deviations from institution policy or accepted standards.
- Develop a description of the role and rationale for a health care institution manager’s participation in the risk management process.
Prerequisite: Philosophy of Managed Care (AHA 209)
3 hours each week or weekend format 3 credits