Hospital Utilisation Management

The Hospital Utilisation Management (HUM) programme manages hospital admissions and inpatient treatment of patients to assure rational, appropriate and cost effective in-patient care through a process of:

  • Prospective review through pre-authorisation
  • Concurrent review through case management
  • Prospective review through discharge management
  • Retrospective account review
  • Analysis of utilisation, risk factors and review of costs incurred and
  • Benchmarking and reporting to the scheme

The HUM service keeps track of all hospital in-patients and monitors the quality of care in terms of whether it is rational and appropriate – the correct care at the right time.

Interventions are performed when cases vary from the norm in respect of Length of Stay (LOS), Level of Care (LOC), Theatre interventions, treatment modalities, PMB requirements or cost.

An analysis is performed on hospital authorisation and claims data and MHS establishes such norms through utilisation of the MHS Hospital Profiling software and systems- and through the application of appropriate clinical expertise from the clinical management team.
In order to fulfil the service obligations to the client, MHS undertakes the following tasks:

  • Pre-authorisation of hospital admissions prior to hospital admission
  • Confirmation and Authorisation once the patient has been admitted to hospital
  • Authorisation of treatment in-lieu of hospitalisation
  • Case Management
  • Discharge Management
  • Clinical advisory services associated with the hospital utilisation management process
  • A variety of reimbursement models can be applied during the Hospital Admissions Management process: Fee for Service (FFS), Per Diem, Fixed fees, Global fees, Net Acquisition Price (NAP) application and Uniform Patient Fee Schedule (UPFS – for private patients attending public hospitals)
  • Analysis and Reporting of utilisation, risk factors and expenditure, and
  • Appeals Process