Blue Cross Blue Shield utilization management plan

¶ … management plan for Kaiser health care facility

In this paper, we will review the utilization management of our chosen health care organization Kaiser, here we will overview many aspects of the utilization plan as well as discuss them. We will also try to describe how each of those elements can contribute to the health care quality of the organization itself. We will also try to identify two weaknesses of Kaiser's utilization management plan and describe why these are deemed as weaknesses. Some postulates would also be proposed which will help in overcoming these weaknesses. Firstly, let's have a review of what the utilization management actually does.

Utilization management

The term utilization management refers to the overall evaluation of medical needs appropriateness and the efficiency of health services procedures as well as facilities according to any formal established guidelines or criteria which is under provision of a proper health benefits plan. "It describes the many proactive procedures which include discharge planning, pre-certification, concurrent planning and different clinical case appeals." (Dabbah, 1999). "This also covers many proactive processes like peer reviews and concurrent clinical reviews alongside appeals which are introduced by patient, payer or the provider." (Smith, 2006).

In the case of Kaiser, there are many different functions regarding its utilization management which can promote better health care as well as better standards of operations within the organization itself. It is these basic but necessary things which can make a huge impact on not only the patients who come for treatment but on others individuals as well such as the relatives of patients, doctors or nurses in having a better and much more caring standard of living for not just themselves but for those who surround them.

Let's review some of the plan's essential functions, the departmental operation oversight function helps in overlooking the entire operations performed by any department and report if any sort of irregularities are being done, this helps in bringing a positive and constructive change within the department itself. The plan also provides leadership as well as guidance towards consultancy with other different members of health care team, this greatly helps the learning process of the personnel associated with the department as they can share their experiences among each other.

The plan directs the staff review of UM related aspects regarding treatment and discharge plans in order to ensure the cost-effective as well as high quality discharge planning, here the UM is a department which organizes these mentioned things as well as other related matters and this sort of planning greatly facilitates in doing the tasks properly in time and much more efficiently resulting in more consumer satisfaction as well as earning their trust. The responsibility towards repatriation, claims management as well as ambulance can also fall under the utilization plan. The utilization plan can make all of these things more accountable towards the management on how they perform their day-to-day tasks and duties resulting in much more efficient and better services provided to the patients.

The plan also helps in resolving and managing different issues such as human resources, departmental safety, risk management and so on. It is also responsible for all aspects of the staff management which includes issues such as personnel training, hiring, performance reviews as well as terminations integrated in broader medical center's overall utilization management initiatives. This also helps the upper level management in doing their routine tasks with more efficiency and better understandings of ground realities.

The plan also includes the assurity of the development, implementation and monitoring of the policies and procedures of all the departments. It also ensures that the member benefits are properly interpreted and applied correctly such that they come in compliance with the federal and state regulations. This also includes the overseeing of data entry as well as the documentation.

The previously mentioned are some of the main points which are in Kaiser's utilization management plan. Now, let's look at some of the weaknesses in this plan. Although the plan calls for many creative solutions such as departmental operational overseeing as well as proper management, it fails to go into the details of how these tasks should be achieved. Here, more emphasis should be given on how the mentioned and other points in the utilization plan should be achieved. This will greatly simplify any person or organization that will choose to follow such plan in order to make the organization a better place. The management should also be able to hire the expertise from different other firms in order to accomplish this task.