Talk:Utilization review

Note I realize that this page was previously deleted. However, this created unresolved hyperlinks in a couple of my original content articles. The disambiguation between "Utilization review" page and "Utilization Management" page, for which Utilization Review was deleted as meaning the same thing, points out that there is a difference between utilization review and utilization management. The context in my articles intended the specific context of "utilization review," as in the review in RETROSPECT of Managed Care preauthorization decisions made.

This is extremely important in ERISA cases, as many States including Texas have mandated retrospective REVIEW of managed care utilization review decisions. Such review are among the so-called "panoply" of remedies claimed in decisions like CIGNA v. Calad to prevent the very thing which caused Calad's pain and suffering, such that the pain and suffering would never happen, and monetary damages might not be needed -- that the CIGNA Nurse's decision that 1 day of hospitalization was sufficient even before Calad's admission or surgery, would be "REVIEWED" the next day, presumably with input from her physician, a copy of the operative notes, and a Board of CIGNA PHYSICIANS, not NURSES, reviewing the recommendation of the CIGNA physician, before the fateful premature discharge occurred and caused the pain and suffering. In such a way, CIGNA's and Aetna's attorneys argued that the triad of equitable remedies available under ERISA were sufficient for cases involving what would otherwise be tried as medical malpractice under State Jurisdiction and the State's obligation to regulate Healthcare and Medical Licensing and Insurance for its citizens, rather than Healthcare be an ill-conceived afterthought to be managed in a Federal System not meant to deal with such matters, on the basis that some Amendment in the 1940s gave the Federal Government the right to regulate interstate commerce. MarySteinborn (talk)


 * I don't see where there's enough for utilization review to have a stand-alone article. However, it is covered in the utilization management article, where the two terms are distinguished, so it's reasonable to have this article be a redirect to Utilization management. I'm boldly doing that. —C.Fred (talk) 00:02, 26 April 2012 (UTC)

Respectfully, I believe there is a big difference between the definition of Utilization review and Utilization management. "Utilization Management" has the connotation of "doling out" of a limited amount of funds as seen fit by the Managed Care Entity. This would be similar to Socialized Medicine or Government-run Healthcare. On the other hand, Utilization Review has the connotation that there is an appeals process, where perhaps a doctor recommends a procedure for a patient, and if the Insurance company has reason to doubt the cost versus benefit of the procedure, first the doctor could appeal to physician of the same specialty hired by the Insurance company. If the review were denied, a higher level of review could take place with perhaps an Independent Review Board consisting of Physicians qualified to make the determination particular to the individual case.

The main difference here is that Utilization review is PRO-active. It happens before the procedure is decided upon and before the procedure takes place.

CIGNA v. Calad involved a case of "doling" of 1 night of hospitalization for a hysterectomy, apparently by a "Utilization management" Nurse who worked for CIGNA, before the surgery even took place. With husband and wife dealing with the presumed emotional stress of a fairly major surgery, Mrs. Calad was discharged the following morning and suffered complications from the surgery that caused her to have to be emergently readmitted.

Much talk was had in the arguments before the Supreme Court in Aetna et. al. about what Ms Calad "might have done" to prevent the emotional stress and physical pain which might have been shown to have resulted from the pre-surgery doling out of 1 night's hospitalization by a CIGNA nurse.

And it is a true Utilization review process that might have prevented the complications and incumbent suffering for Mrs. Calad. Ms Calad would not have been discharged from the hospital on postoperative day 1 if a true Utilization review process had determined a reasonable length of stay to begin with, which could then be fine-tuned according to the results of the surgery and the opinion of the surgeon providing the care, appealed in a timely manner (timely being before her discharge) as necessary. A true Utilization review might have allowed Ms Calad to be discharged when it was appropriate for her individual case, and thus her injuries and suffering prevented.

I contest quick deletion for this reason. The CIGNA v. Calad is an extremely important ERISA Supreme Court Landmark Case that, as many Judges have stated, need to be revisited by Congress or the Supreme Court.

CIGNA v. Calad

MarySteinborn (talk) 15:25, 30 April 2012 (UTC)


 * That's why CIGNA v. Calad has an article: it's a notable case. It does not mean that utilization review automatically warrants its own article because it's mentioned there. Right now, it's covered at utilization management, and I don't see enough material there to justify a split. —C.Fred (talk) 00:35, 1 May 2012 (UTC)


 * By the way, the last speedy deletion was under criterion A3, an article consisting of only a restatement of the title of the article. —C.Fred (talk) 00:36, 1 May 2012 (UTC)