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Payers commonly implement utilization management to reduce health care costs.
FREMONT, CA: Health care utilization management (UM) is an approach to reducing health care costs. Although successful programs do result in reduced claim costs, the primary objective of a successful UM program is to enhance the quality of care. When UM programs prioritize cost savings over patient care by focusing on denials, they frequently increase the cost of a claim. Denial of claims for the sole purpose of cost reduction can impede early intervention and lead to more expensive procedures in the future due to a delay in care. Effective UM programs are predicated on administering the appropriate patient care at the proper time. Program components include risk management, quality assurance, education, and utilization review. Risk management Risk management seeks to improve the quality of care for patients and prevent avoidable costs through early intervention, preventative health, and education. Early Intervention: Early intervention is used to halt the progression of a disease, thereby preventing a decline in quality of life and escalating healthcare costs. The expectation is that the disease process will be completely reversed. Preventive health: By implementing healthy lifestyle choices, preventative health attempts to prevent the disease from ever occurring. It also seeks to identify potential disease processes early on to improve the population's health and, in turn, reduce costs. Education: Educating patients about the disease's signs and symptoms enable early diagnosis and treatment. In addition, education provides patients with knowledge of best practices regarding annual checkups, preventive care, and the insurance benefits available to them. Utilization review: Utilization review determines the adequacy of the prescribed treatment plan to guarantee a high level of care and prevent unnecessary procedures. It is divided into three review phases: prospective, concurrent, and retrospective. BEST PRACTICES FOR A SUCCESSFUL UM PROGRAM Define processes, responsibilities, and policies with precision A clearly defined utilization review process that outlines each step and the roles and responsibilities of each team member guarantees quality, repeatability, and sustainability. The success of a UM program needs to have robust policies and procedures in place, including topics such as admissions/requested services guidelines, a comprehensive list of professional services offered, and care setting reviews. Employ a dedicated physician consultant to oversee utilization review All UM staff conducting utilization reviews and the UM program should be supervised by seasoned clinicians with a comprehensive understanding of health care policies, UM standards, and revenue cycle processes. UM, initiatives are successful because these advisors possess critical thinking, problem-solving, and decision-making skills. It enables them to see the bigger picture regarding patient care–clinical and legal aspects, not just financial ones—while imparting their knowledge of the best practices and standards of care in their respective medical fields to nursing staff. Ensure that the quality improvement program is robust All clinical processes and clinical decision-making must be audited to ensure regulatory compliance and the appropriate application of medical necessity guidelines. A robust quality improvement program enables audit results to become actionable information. Staff coaching, providing refresher education, revamping training materials, and updating workflows are just some actions that can take in response to the findings of quality audits. Resulting in more competent and consistent staff, more efficient case management, higher quality results, and better patient outcomes.
