What is Utilization Management Utilization management is the evaluation of the appropriateness, medical need and efficiency of health care services procedures and facilities according to established criteria or guidelines and under the provisions of an applicable health benefits plan. Typically it includes new activities or decisions based upon the analysis of a case. The Institute of Medicine defines utilization management as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision” Standard utilization management services include prospective review, concurrent review, retrospective review, pre-certification of hospital stays, and discharge planning.
Purpose of a utilization management programme To assure the effective and efficient utilization of hospitals, physician providers, facilities, case management services, ancillary services and social services. Services are medically necessary, delivered at an appropriate level of care, place of service and consistent with criteria and clinical practice guidelines To continually assess and improve as necessary, member access to care as well as quality of care available to members. To comply with local and regional healthcare delivery regulations and accreditations. Under or over utilization of services is not occurring To comply with local and regional healthcare delivery regulations and accreditations.
Benefits offered to a provider Enhancing the standards and quality of care by providing medically necessary treatment to an appropriate patient group after stratifying the medical risks and instituting timely therapeutic interventions. Multidisciplinary teams collaboration in designing appropriate care pathways, treatment protocols, medical and surgical interventions for a patient group. Reduction in Length of Stay (LOS) resulting in higher patient turnover leading to incremental profits and a higher capacity. Decreased health care spending in avoiding excessive use of healthcare resources without yielding the desired benefit. Tangible cost savings over a period of time by adhering to evidence-based clinical guidelines and doing a periodic utilization review to achieve an optimum state of healthcare delivery. Possible shift in clinical treatment philosophy from medical management to disease management. Efficient resource utilization and improved decision making in investments based on the current utilization rates and patterns.
GuidelinesA utilization management programme in a hospital setting is based on the use of nationally recognizedguidelines such as McKesson’s InterQual® Criteria or Milliman Care Guidelines®.
McKesson’s InterQual® Criteria InterQual® clinical criteria and software is a market-leading solution that help payers and providers determine the appropriate use of healthcare resources and improve the quality of care. The InterQual suite helps payers, providers and other organizations share a common language for determining the evidence-based clinical appropriateness of both medical and behavioral health patient services, ranging from care settings to diagnostics and treatments. InterQual® Acute Criteria enables the case manager to determine if the care is clinically indicated and at the appropriate level of care. Source: Mckesson website
McKesson’s InterQual® CriteriaInterQual helps to: Reduce over- and under-utilizationi. Drive appropriate care with same source, rules-based, patient-specific EBM (evidence-based medicine) decision support.ii. Reduce re-admissions, LOS (length of stay) and services with integrated tools for complex and co- morbid cases. Increase defensibility and reduce riski. Validate appropriate care with quality indicators, checklists and reporting.ii. Drive cost efficiencies through Clear Coverage™, the InterQual auto authorization solution. Align stakeholdersi. Drive consistency with same source, rules-based, customizable EBM decision support.ii. Align with CMS guidelines.iii. Reduce administrative expense with fewer denials and appeals.iv. Improve quality with more time available for patient care. Support stakeholder performance managementi. Facilitate medical and payment policy decisions with rules-based EBM.ii. Identify practice trends and areas for quality improvement.iii. Identify high-quality, high-performing providers for ‘gold-carding’ and tiered networks. Source: Mckesson website
Milliman Care Guidelines® Milliman Care Guidelines are evidence-based clinical guidelines including care pathways that help providers and payors in effective decision making for the patient care. Milliman Care Guidelines® are annually updated, evidence-based clinical guidelines that span the continuum of care, including chronic care and behavioral health management. They are either client-hosted or web-based software that readily interfaces with many medical management and clinical information systems. Interactive version CareWebQI® enables quality improvement and cost efficiency through targeting and reducing inappropriate care. It helps in identifying gaps in care and cause of variation thus reducing their occurrences. Indicia® for Utilization Review helps clinical teams make admissions decisions and utilization managers justify admissions, level-of-care assignments, and procedures to safeguard reimbursements and meet the challenges of RAC audits. Source: Milliman website
Overview of a Utilization Management ProgrammeAny Utilization Management programme’s mission is to provide a decision support system forclinicians and managers. It may provide feedback on service utilization to clinicians and managers onbehalf of clients. The programme intends to monitor and report on system wide service utilizationpatterns. It may also provide concurrent utilization review of individual client service needs. UM Plan Clinical ToolsClinical (Medical) Necessity Criteria (Services recommended in the treatment planmust meet all of the following criteria) 1. Treatment must be no more and no less than the client requires based on diagnosis/symptoms/ behaviors/skills/abilities/functioning 2. Treatment is safe and effective according to national standards 3. Treatment is in the least restrictive setting 4. Treatment is cost effectiveSource: UM Plan for DuPage County Mental Health
Utilization ReviewUtilization Review is a process used to evaluate requested health care services and determine if theyare Medically Necessary.It is usually of following types:i. Prospective Reviewii. Concurrent reviewiii. Retrospective reviewRole of Utilization Review is to validate: the necessity of medical service requested if the duration of service requested is within the prescribed range the amount or intensity of service required is appropriate in a given situation
Outcomes of Utilization Management Possible enhancement of quality and effectiveness of patient care Possible reduction in ALOS leading to increased profitability Improved healthcare outcomes for the patients providing positive brand value to the provider Predictability in care pathways and treatment measures instituted Reduction in revenue leakages and aligning investment decisions more towards future costs and business efficiency Enhancing competitiveness of the provider