Utilization Management vs. Case Management vs. Disease Management Explained

By: Eric Bricker, MD

Utilization Management (UM), Case Management (CM) and Disease Management (DM) are three healthcare and health insurance terms that are often confused. Let’s look at each of these functions, how they are similar and how they are different. 


Utilization Management 


Utilization Management involves a nurse from the insurance carrier approving ‘bed days’ for a hospitalized plan member. UM is primarily used for inpatient stays at a hospital such as for a heart attack (myocardial infarction), cancer treatment or major abdominal surgery. The UM nurse from the insurance company speaks with the UM nurse at the hospital about what is going on with the patient. The UM nurse from the insurance company then determines if the patient meets ‘inpatient criteria’ to be kept in the hospital for continued treatment. 


If the patient meets ‘inpatient criteria,’ then the insurance company nurse approves a certain number of ‘bed days’ (typically 1-3) and will check back with the hospital in that amount of time to see if the patient is still hospitalized and still meets ‘inpatient criteria.’ 


If the patient does not meet ‘inpatient criteria,’ then the insurance company nurse lets the hospital know that the patient’s care will be denied payment when the hospital submits the bill. The hospital can appeal this determination based on a review of the patient’s chart after discharge.  


Case Management 


Case Management involves a nurse from the insurance carrier trying to reduce or stop readmission of plan members that have been discharged from the hospital to 1) acute rehab, 2) a skilled nursing facility, 3) a long-term acute care facility or 4) home with home health services. 


For example, the insurance company CM nurse may contact a patient after they have been discharged home for a total knee replacement with home health and/or home physical therapy services. The CM nurse will make sure the home health and physical therapy are going well and if there are any issues, they will work to resolve them with the home health agency or physical therapist. 


Disease Management 


Disease Management involves a nurse from the insurance carrier or disease management vendor working with the patient and his or her doctors and other providers to manage a chronic disease such as 1) Diabetes, 2) COPD, 3) Congestive Heart Failure or 4) Chronic Kidney Disease. 


The DM nurse will speak with a patient on the phone about healthy eating and exercise as it relates to the patient’s specific condition. The DM nurse will also speak with the patient about his or her medications to make sure he or she is taking them correctly. The DM nurse may also counsel the patient on other condition-specific care, such as checking blood glucose levels for an insulin-dependent diabetic. 


As you can surmise from the above paragraph, the success or failure of the DM nurse hinges on their ability to successfully contact the patient by phone. Non-contact with patients has historically been a challenge for DM. 


An Innovative Addition 


SimplePay Health uses an additional approach of working with patients when they are first making an appointment with a doctor. SimplePay Health is notified at the time of scheduling that a plan member is seeking care and contacts the person to let them know how much their visit will cost in advance AND of any potentially higher quality, lower copay doctors of that same specialty in their area. 


Closely tying 1) high quality care, 2) lower copays and 3) proactive outreach at the beginning of care is a much better way to move patient care in the right direction from the start. 


To learn more about SimplePay Health, schedule time with our sales team today!  


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