exam 3 (4) - Missed first 25 E. Two basic kinds of managed...

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Missed first 25 E. Two basic kinds of managed care 1. external utilization review – 3 rd party insurance company cuz they have the financial review. So they review the costs 2. internal utilization review – hmo does it itself? V. Detalied example of external UR for mental illness hospitalization A. patient shows up at hospital ER in crisis B. Patient presents insurance card C. Hosp calls to verify insurance D. patient admitted for 23 hrs for “eval” E. First 23 hours F. discharged after 3-5 days (if approved for further care after first 23) Cram all treatments in those days Give psycho drugs – antidepressants, tranquilizers (prob: most drugs take 10d- 2weeks to get correct dosage)…either dose to high or to low. (side effects or drugs no work). No like er so no return. Or come back if bad. G. discharged if patient exceeds yearly limits ( so no cost 2 much) III. Internal utilization review Hmo does internal review. Usu in hmo w/ capitated treatment plan The care manager works inside the hmo. So he works w/ the docs and all. SO the
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exam 3 (4) - Missed first 25 E. Two basic kinds of managed...

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