A client is a member of an HMO and has chronic shoulder pain from an old injury. The client has decided to pursue shoulder surgery and the HMO has required a utilization review. His review will focus on The costs and benefits of the proposed surgery.
- Health maintenance organization is referred to as HMO. Doctors, hospitals, and other healthcare professionals that have agreed to accept payment at a specific level for any services they perform are part of an HMO's network.
- Insurance companies use the utilization review process to determine the need for medical care and to guarantee that payment will be made for the care.
- Precertification or preauthorization for elective treatments, concurrent evaluation, and, if necessary, retrospective review for emergency cases are all common components of utilization review.
- Profits are usually a pertinent factor, but many other factors would be taken into account.
- A utilization review does not primarily focus on the client's baseline functioning or the circumstances of the first injury.
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