Practice Quiz

Managed Care Nursing

Category - Overview

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Select the answer that best describes the earliest and most accurate historical indications of utilization management.
  1. Utilization management appeared around 1950 in the private healthcare sector, prior to the existence of HMOs.
  2. California increased requirements around the Medicaid program in 1970 to include preadmission and concurrent review of hospital admissions.
  3. In 1959, healthcare agencies in Pennsylvania began to look at retrospective data related to hospital claim outliers.
  4. In early 1950, healthcare agencies in Washington State under the direction of Dr. Ellwood formed a peer organization to review retrospective data from hospital admissions.
Explanation
Answer: C - The earliest and most accurate historical indications of utilization management was in 1959 with healthcare agencies in Pennsylvania. These agencies began to look at retrospective data related to hospital claim outliers.

A group of healthcare professional organizations in Pennsylvania, including Blue Cross of Western Pennsylvania formed a conglomeration. The goal was to retrospectively review hospital claims that fell outside of the average cost range. There is no indication of utilization management in the private sector in 1950 or with Dr. Ellwood playing a direct role in the UM process. The statements about California are true; however do not reflect the earliest indication of UM.
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