A healthcare quality analyst compiles and analyzes data to facilitate performance improvement opportunities. The most suitable data review to…

A prospective review is the most suitable process to proactively control costs. This type of review, also known as pre-authorization or pre-certification, evaluates the medical necessity and appropriateness of care before services are rendered. By assessing planned procedures, admissions, or high-cost medications in advance, the organization can prevent unnecessary utilization and associated expenses. This proactive approach allows for interventions, such as suggesting a less costly but equally effective alternative, before resources are consumed, directly controlling costs.

A. Retrospective review analyzes care and costs after services have been provided, making it a reactive tool for identifying past trends, not for proactive control.

C. Administrative claims review is inherently retrospective, as it analyzes billing data submitted for payment after care has been delivered.

D. Clinical records can be used in any review type, but "prospective review" is the specific term for the proactive process of evaluating care before it occurs.

1. Pojasek

R. B. (2011). The new view of quality. Environmental Quality Management

21(2)

93-102. https://doi.org/10.1002/tqem.20311 (Discusses the shift from reactive (retrospective) to proactive and predictive quality approaches).

2. Kongstvedt

P. R. (2012). The Managed Health Care Handbook (4th ed.). Jones & Bartlett Learning. (Chapter 10

"Utilization Management

" clearly defines prospective

concurrent

and retrospective review

identifying prospective review as the mechanism for pre-service authorization and cost control

pp. 165-167).

3. American Health Information Management Association (AHIMA). (2016). Utilization Management Toolkit. (The toolkit describes prospective review as a primary tool for managing healthcare costs by determining medical necessity prior to service delivery).