Utilization Management is an integral part of the US healthcare ecosystem used by health insurers or Pharmacy Benefit Managers (PBMs) to evaluate the appropriateness, medical necessity, and efficiency of healthcare services rendered to patients.

1. Shridhar Purohit is a Healthcare IT consultant with extensive experience in devel-
oping product strategy, consulting and implementation of health care business
solutions. He has worked in delivering multiple life-cycle engagements from
concept to solutions across all product lines such as EMR, EHR ,Population Health
Management Solutions (Utilization Management and Care Management Applica-
tions) ,Life Sciences application CTMS (Clinical Trial Management System).
Shridhar Purohit
HEALTHCARE UTILIZATION
MANAGEMENT SOLUTION
Implementing a successful Healthcare Utilization management
program using automation and technology

2. Utilization Management is an integral part of the US healthcare ecosystem used by health
insurers or Pharmacy Benefit Managers (PBMs) to evaluate the appropriateness, medical
necessity, and efficiency of healthcare services rendered to patients.
Utilization management aims to:
Improve the quality of service at the right cost, in the right setting, without
overwhelming delivery and reimbursement systems with administrative burden.
Address the clinical activities of in-patient admissions based on case analysis.
For health plans, it is used to evaluate the appropriateness and medical necessities
of health care services, procedures, and facilities according to evidence-based
criteria or guidelines.
UM processes typically include authorizations, approvals, escalation processes when a
clinician and UM reviewer are unable to resolve a case, MD review, case assignment etc.
There are many roles that are vital across UM processes. A few key roles are UM review-
ers (often a Registered Nurse with UM training), UM program manager and physician
adviser.
UM activities evaluate many aspects of patient care, such as
The timeliness of services
The amount of medication prescribed
The number of bed days used in a hospital
Patient recovery time
1 Copyright © 2018 Nalashaa

3. Improve authorization review process by
Implementing auto approvals through application
of standard or custom criteria. This will align organi-
zations with value-based care, where provider-pay-
er communication is expected to be in real-time to
guide timely decisions
Implementing reliable and well-informed third-par-
ty reviews
On clients’ request, the system can securely be
integrated with one of the following third-party
applications to provide care guidelines:
Care WebQI Guidelines (CWQI)
InterQual
Implement Palliative care Management
Some of the palliative care measures which can be
implemented are
Telehealth technology to connect patients with
palliative consultation teams, eliminating the
inconvenience of traveling to hospitals or
emergency departments for care
Incorporating palliative care assessments
helping case managers to assess the patient
for palliative care management
Implementing automated discharge planning
Enabling discharge assessment and triggering case
management referral based on the assessment
outcome
This will reduce chances of readmission and
increase patient satisfaction
Improving provider management by
Implementing provider portals enabling authoriza-
tion creation, authorization submission, provider
attachment, informative dashboards etc.
In/ Out network provider management by imple-
menting in/out of network algorithms per client
requirement
Enabling the out of area provider access to provider
portal as per client requirement
Alerts management by alerting the provider
with industry standard and custom alerts
Conclusion
As healthcare in US is moving towards
value-based care, Utilization Management
is evolving as must concept to efficiently
manage the resources which in-turn
improves the ROI while providing quality
service. Even though, it began as a way for
health care organizations and profession-
als to evaluate the efficiency and effective-
ness of the services provided to the
patients, it has emerged into a proactive
planning and decision-making solution.
Availing the progressions in technology,
utilization management has the potential
to revolutionize the services of providers,
payers by providing cost effective quality
care, if implemented intelligently.
If you would like to bounce off your thoughts on
this, let’s have a conversation.
Connect with
the experts!
At Nalashaa, we partner with healthcare organizations of all
stages, from startups to established firms, and work with them to
build engaging user experiences that reduce organziational cost
and risk. Our healthcare and technology expertise, along with our
flexible engagement models, make us a great fit for developing
the quality technology while reducing time to market and
engineering costs.
About Us
555 US Highway 1 South, Suite 170, Iselin, NJ 08830, USA
732-602-2560 X 200 www.nalashaahealth.com
Reach Us: