Does your healthcare facility need to outsource or improve its utilization management (UM) services? Utilization management in healthcare can be a complex process that helps enhance the quality of healthcare and reduce costs. In general, UM, especially if it’s practiced by as many healthcare facilities as possible, also improves the population’s overall health.
Efficient UM services ensure that your patients get the care they require without unnecessary costs, care they don’t need, and excessive testing. Because the healthcare industry is changing rapidly due to new discoveries and updated standards, UM services may catch problems that even the most experienced medical professionals may overlook. This can vastly improve the quality of any healthcare management or treatment program. If your healthcare facility is having trouble with managing utilization management services, contact CodeMax Medical Billing today. Call 866.471.3267.
What Is Utilization Management?
You might be thinking: “What is utilization management?” After all, it’s not a term that’s often used in casual conversations.
So, what is utilization management? It is a process that became popular in the 1970s but became more prevalent in the 1980s and succeeding decades, at around the time healthcare costs started to increase more significantly than they had in the decades before. One of the key goals of UM is to keep costs down for healthcare insurers and employers.
UM services take care of three main types of reviews, all of which can impact work processes differently. Types of reviews that UM services provide include:
- Prospective review – This pre-service review ties in nicely with prior authorization tasks. This review is designed to eliminate unnecessary tests and forms of care and is performed before or at the onset of patient treatment, usually on a case-by-case basis. It also reviews requests for and denials of procedures, programs, and medications that aren’t covered by a patient’s insurance. All parts of a treatment program should be considered contingent, although they may be changed later.
- Concurrent review – This type of review occurs during patient treatment. It tracks a patient’s progress and resource consumption. If UM services identify a problem, it may cause in-process care procedures to stop at a certain point.
- Retrospective review – This post-service review is conducted after a patient’s treatment is done. It assesses the appropriateness and efficiency of the treatment in order to provide data for future patients. This type of review also looks at appeals for procedures, programs, and medications that were denied coverage after their delivery.
What Are the Benefits of Utilization Management?
A well-run UM program benefits all parties involved, whether it’s the patients, the healthcare providers, or the insurers. The advantages for each include:
- Patients – They get fewer claim denials, lower costs, and more effective treatments.
- Healthcare providers – Like patients, healthcare providers get fewer claim denials and lower costs. They also get better data and resource deployment, as well as more effective treatments offered.
- Insurers – Like healthcare providers, insurers get lower costs and better data. They also get consistent evaluations of the effectiveness of new treatments and protocols.
Why Is Utilization Management in Healthcare Important?
In general, UM looks at the effectiveness of treatments for each patient at every point in the treatment process: before they occur, while they occur, and after they are over. This analysis contributes to the succeeding goals of UM, which are improving patient care and increasing the overall health of the population.
UM evaluates the efficiency, appropriateness, and medical necessity of all the treatments, services, procedures, and facilities provided to patients on a case-by-case basis. Healthcare facilities, medical staff, insurers, and patients are all affected by the results of UM services.
Medical services by UM might include:
- Home health visits
- ER visits
- Inpatient admissions
- Inpatient days
- Outpatient visits
- Skilled nursing facility (SNF) admissions
- SNF inpatient days
Other metrics are typically tracked by the number of patients per month or year. These metrics can include cost per visit, high-cost imaging such as MRI or PET, primary care physicians visits, and specialty referrals.
Explore Utilization Management Services at CodeMax Medical Billing
If your healthcare facility is having trouble managing utilization management services, contact our CodeMax Medical Billing team today by calling 866.471.3267 or filling out our online form. Choose CodeMax as your partner for utilization management services.