Describe the two basic approaches to utilization management: prospective and retrospective review.

Prospective re-view/precertification: the service is examined before it is provided. Data is collected, usually by a nurse, from the patient and the physician. The facts of the individual case are compared to the appropriateness criteria. If the standards are met, the nurse can usually approve the service. If the standards are not met, a physician advisor may be asked to review the case and make a determination. Types of activities typically undergoing prospective review include authorization for referral, authorization for a procedure, preadmission review before hospitalization, and second surgical opinion.
Retrospective review: in this methodology, care is looked at after it is given. Usually a sample of cases is selected. Data is then collected from medical records, and the information from the record is compared to the appropriateness standards. Feedback is then given to the appropriate caregiver regarding inappropriate care provided.