Murray Mary Ellen, Darmody Julie V
School of Nursing, University of Wisconsin-Madison, K6/340 Clinical Science Center, 600 Highland Avenue, Madison, WI 53792, USA.
Outcomes Manag. 2004 Jan-Mar;8(1):19-25; quiz 26-7.
Concurrent utilization review (UR) is both a quality improvement tool and a cost containment strategy used by managed care organizations. The UR process requires that providers (hospital staff) communicate clinical information about hospitalized patients to payers who evaluate the appropriateness and medical necessity of the planned care. Payers then make a decision whether to certify the care for reimbursement. This study provides data to indicate that denials of certification have little impact on clinical and fiscal outcomes of patient care.
同步利用审查（UR）既是一种质量改进工具，也是管理式医疗组织所采用的一种成本控制策略。UR流程要求医疗服务提供者（医院工作人员）向支付方传达有关住院患者的临床信息，支付方会评估计划治疗的适宜性和医疗必要性。然后，支付方决定是否批准该治疗以进行报销。本研究提供的数据表明，认证被拒对患者护理的临床和财务结果影响甚微。
