A case study of state managed care regulation: utilization review laws
Article Abstract:
The nature of utilization review (UR) gives it both quality assurance and cost management functions. Utilization review firms or agents exist primarily to evaluate patient care recommendations made by medical practicioners. Review agent qualifications and UR encroachments on the responsibilities of health care providers are issues which have raised clamors for government regulations. Aspects of UR already being addressed by state legislative proposals include accessibility of UR agents especially for emergency cases, confidentiality of patient's medical records and appeals mechanisms.
Publication Name: Benefits Quarterly
Subject: Human resources and labor relations
ISSN: 8756-1263
Year: 1992
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Provider responses to utilization review
Article Abstract:
Utilization review has been used extensively by health care purchasers to determine unnecessary, inappropriate and questionable health care services. However, health care providers consistently argue that utilization review has made patients vulnerable during key phases of health care, shifted medical costs away from third party payers and burdened the administrative aspect of providing medical care. Because of increasing conflicts with reviewers, health care providers have developed proactive strategies and organized themselves politically to counteract utilization review.
Publication Name: Benefits Quarterly
Subject: Human resources and labor relations
ISSN: 8756-1263
Year: 1992
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Regulating managed care firms: the Connecticut plan
Article Abstract:
Managed care is still an evolving industry in the US and thus still has no national regulatory standards. The Connecticut legislature, realizing the importance of the industry, commissioned the University of Connecticut's Center for Health Systems Management to determine how managed care should be regulated. After studying utilization review (UR) practices of firms doing business in Connecticut and the responses of medical care providers to UR, researchers recommended regulations covering licensure, oversight, standardized practices and penalties for failure to perform.
Publication Name: Benefits Quarterly
Subject: Human resources and labor relations
ISSN: 8756-1263
Year: 1992
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