Utilization management describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It also covers proactive processes, such as concurrent clinical reviews and peer reviews, as well as appeals introduced by the provider, payer or patient.
As pre-certification and concurrent review of cases grew, utilization management spun out of utilization review.
While not synonymous, health care professionals tend to use the terms as interchangeable. The difference is utilization management is forward looking and intends to manage health care cases efficiently and cost effectively before and during health care administration. Utilization review is more backward looking considering whether health care was appropriately applied after it was administered.