Practice guidelines and utilization management guidelines: Are based on reasonable medical evidence or a consensus of health care professionals in the particular field; Consider the needs of the enrolled population; Are developed in consultation with contracting physicians; and Are reviewed and updated periodically.
Full Answer
What are the functions of utilization management?
Utilization management (UM) is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis.This process is run by — or on behalf of — purchasers of medical services (i.e., insurance providers) rather than by doctors.
What is an utilization management plan?
Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review.”
What is the definition of utilization management?
What is utilization management? Utilization management is a set of techniques purchasers of health care benefits use to evaluate the medical necessity, efficiency and appropriateness of health care services. This helps patients eliminate unnecessary costs of testing and care they don't need.
What is utilization management?
Utilization Management is a key business process that ensures the delivery of medically necessary care. The NCQA accreditation in each of these areas demonstrates LIBERTY’s commitment to the ...
What is utilization management in Medicare?
Utilization management (UM) is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan, sometimes called “utilization review.”
What are utilization guidelines?
Utilization management (UM) or utilization review is the use of managed care techniques such as prior authorization that allow payers, particularly health insurance companies, to manage the cost of health care benefits by assessing its appropriateness before it is provided using evidence-based criteria or guidelines.
What are the basic three components of utilization management?
"Utilization management is the integration of utilization review, risk management, and quality assurance into management in order to ensure the judicious use of the facility's resources and high-quality care."
What are the 3 assessments for utilization management?
There are three activities within the utilization review process: prospective, concurrent and retrospective.
What is the goal of utilization management?
The goal of utilization management is to assure appropriate utilization, which includes evaluation of both potential over and underutilization. cost-effective use of health care resources. To ensure transition of care is addressed as members move through the healthcare continuum.
What is the difference between utilization review and utilization management?
While utilization review identifies and addresses service metrics that lie outside the defined scope, while utilization management ensures healthcare systems continuously improve and deliver appropriate levels of care. Reducing the risk of cases that need review for inappropriate or unnecessary care.
What are the MCG guidelines?
MCG Care Guidelines are written to address the clinical circumstances of the majority of people. However, an individual's unique clinical circumstances will be considered in light of these policies and peer-reviewed, evidence-based scientific literature.
What is the difference between utilization management and case management?
The key differences between the two models are the integration of utilization management into the role of the case manager versus the separation of the role through the addition of a third team member.
What are InterQual criteria?
InterQual® criteria are a first-level screening tool to assist in determining if the proposed services are clinically indicated and provided in the appropriate level or whether further evaluation is required. The first-level screening is done by the utilization review nurse.
What is InterQual and MCG?
The two predominant sets of criteria, MCG and InterQual, differ in many ways but they have one thing in common: They are both clinical screening criteria that are used to recommend the medical necessity and proper setting for care – in this case whether outpatient with observation or inpatient status is appropriate.
What does mcg stand for in utilization management?
Utilization Review Criteria: Introduction to MCG (Part of the Hearst Health Network) - Introduction. General Introduction to the Utilization Review Criteria: Introduction to MCG (Part of the Hearst Health Network)) Inpatient and Surgical Care. Introduction. Applying the Clinical Indications for Admission or Procedure.
What do you do in utilization review?
Utilization review nurses perform frequent case reviews, check medical records, speak with patients and care providers regarding treatment, and respond to the plan of care. They also make recommendations regarding the appropriateness of care for identified diagnoses based on the research results for those conditions.
How does utilization management work?
There are some aspects of utilization management that are specific to prescribing drugs and tracking their effects. For example, many drugs require prior authorization before they can be dispensed. This authorization step allows the insurer to verify if there are lower-cost or generic options available, and also reduces the chance of addiction and abuse. Quantity limits also prevent waste and reduce the potential for abuse and addiction. Patients can also ask for exceptions and medicines, but these must be approved by the insurer before they will be covered. Insurers can also track patient adherence to a treatment plan by refill rates.
What specialties do you need to include in utilization management?
In addition to primary care, pharmacy, advanced care, emergency services, behavioral health, psychiatry and substance abuse, and surgery, you’ll need to include any other relevant specialties. Run utilization management daily, on all cases, and document all key steps in order to provide the best data.
What percentage of medical expenses are covered by high cost cases?
It’s estimated that one to seven percent of patients can account for 30-60 percent of costs. Utilization management case managers focus mainly on reducing costs over other key goals.
What is UM in healthcare?
Utilization management (UM) is a complex process that works to improve healthcare quality, reduce costs, and improve the overall health of the population . This guide explains how it works, who it helps, and why it’s important.
What are the three types of UM reviews?
UM has three main types of reviews: prospective, concurrent, and retrospective. This structure is comparable to the Donabedian model of healthcare quality, developed in the late 20th century by Avedis Donabedian. Each kind of review can impact the process differently.
What is case management?
Professionals can’t always agree on the definition of case management, but according to the Case Management Body of Knowledge, it’s “...a professional and collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services required to meet an individual’s health needs.”
Is UM a template?
Because UM is such an involved and intertwined set of processes and procedures, a simple template would not be helpful. However, the Medicare and Medicaid Conditions of Participation Tenent Healthcare website contains extensive templates that will give you an idea of the amount of work required to set up a UM program.
How often do you have to complete a treatment plan for an inpatient facility?
The treatment plan (individual plan of care) for persons under the age of 21 in an inpatient facility must be completed and reviewed every 30 days.
What is the importance of securing services that do not require prior authorization?
4.2 Securing Services that do not require Prior Authorization. It is important that persons receiving services have timely access to the most appropriate services. It is also important that limited resources are allocated in the most efficient and effective ways possible.
How long does a provider have to notify the Health Plan of an inpatient admission?
The provider must notify The Health Plan within 1 business day of an inpatient admission or demonstrate why timely notification was not possible. If the provider fails to timely notify The Health Plan of admission or demonstrate why it was not possible, a request for retrospective review may be denied.
What is a health plan in Arizona?
The Health Plan has Arizona licensed prior authorization staff that includes a nurse or nurse practitioner, physician or physician assistant, pharmacist or pharmacy technician, or licensed behavioral health professional with appropriate training to apply The Health Plan’s medical criteria or make medical decisions.
What happens if a health plan is unable to establish a single case agreement?
If for any reason The Health Plan’s Contracts Department is unable to establish a single case agreement with an authorized but non-contracted provider. The Health Plan’s Contracts Department will notify Medical Management of an approved single case agreement or unapproved.
What is the role of the clinical team in the service planning process?
As part of the service planning process, it is the clinical team’s responsibility to identify available resources and the most appropriate provider (s) for services using The Health Plan’s network of participating healthcare providers.
Who makes the decision to deny a prior authorization request?
A decision to deny a prior authorization request must be made by The Health Plan’s Chief Medical Officer, physician or Dental Medical Director designee.
How long does a hospital have to review an extended stay?
(3) The UR committee must make the periodic review no later than 7 days after the day required in the UR plan.
Who must be on the UR committee?
At least two of the members of the committee must be doctors of medicine or osteopathy. The other members may be any of the other types of practitioners specified in § 482.12 (c) (1).
What is UR in medical?
The hospital must have in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs. (a) Applicability.