Describe utilization management and common tools used to control care.

• A. Utilization management reviews the necessity and appropriateness of care; tools include pre-certification, concurrent reviews, discharge planning, and criteria-based approvals.
• B. Utilization management analyzes market share and competitor pricing.
• C. Utilization management manages provider credentialing and licensure.
• D. Utilization management oversees facility branding and patient outreach.

Answer: (A)

Utilization management is about ensuring that care is medically necessary and appropriate while using healthcare resources wisely. The main tools used to control care include pre-certification (prior authorization) to approve services before they start, concurrent reviews to evaluate ongoing care during treatment, discharge planning to arrange appropriate post-acute care and prevent unnecessary stays, and criteria-based approvals that apply evidence-based guidelines to determine necessity and appropriate level of care. Other activities like market analysis, provider credentialing, or marketing and outreach fall outside utilization management and serve different goals rather than directly controlling patient-level care.