Utilization Review & Management
The Utilization Review and Management program involves both the member and provider to ensure delivery of the right level of care, by the right provider, in a safe, cost effective manner. The goal of Utilization Review and Management is comprehensive member care rather than fragmented care, delivered and managed at different entry points into the health care delivery system. This approach encourages and supports the development of cost effective alternatives to traditional modes of medical practice without compromising the quality or safety of care provided to members.
Key components of the Utilization Review and Management program include prospective, concurrent, and retrospective review of in-patient member care, coupled with prior authorization of specified outpatient member services.
The Utilization Review and Management program and staff:
- Monitor the use of specific outpatient services and procedures, i.e. MRIs, hysterectomies
- Monitor hospitalizations, i.e. length of stay, in-patient versus outpatient, complications; includes monitoring for appropriateness of admissions to facilities such as Acute Care Hospital, Rehabilitation, Skilled Nursing Facilities, etc.
- Monitors for proper transition of care to the right setting, i.e. skilled nursing facility, home care, rehabilitation facility
ABS Disease Management Programs are designed to lower cost, improve health outcomes and increase member satisfaction with the delivery of healthcare service. The goal of the Disease Management program is to improve quality of life for individuals by preventing or minimizing the effects of chronic disease through increasing knowledge of the chronic disease, improving self-management skills, and enabling a sense of control of the disease process.
Disease management includes communications for populations with chronic conditions in which member self-care efforts are emphasized. It is a population health strategy as well as an approach to personal health.
Examples of chronic diseases our Disease Management focuses on include: Heart failure, COPD and Asthma . Preventive services are also employed including mammography and flu shots to ensure protocols are followed to prevent further illness.
Improving self-care provides opportunity to reduce healthcare costs by preventing exacerbations or progression of the chronic disease.
Case Management is a term used for the activities which ensure coordination of medical services required by a member. The goal of Case Management is to assist members to regain / maintain optimal health or functional capability in the right setting in a cost effective manner. A comprehensive evaluation of the social well-being, mental health, and physical health is done to determine barriers to a member’s adherence to a health plan of care. Case Management covers all the activities of evaluating the member, planning treatment, referral, and follow-up so that care is continuous, comprehensive and cost effective.
Case Managers are licensed registered nurses and social workers who function as advocates, facilitators, and educators, assuring that members make smooth transitions from in-patient settings to alternate care and home care when appropriate. Other benefits and services include:
- Preparation and planning through health management
- Effective communication
- Follow-up and reporting
- Treatment and care facilitation
- Identification of support groups and systems
The Quality Management program reviews and interprets data at both member and provider levels. Patterns of over-utilization of services are addressed and corrective actions taken; member satisfaction with providers is also monitored. Deficiencies are addressed through the Quality Committee and all required reporting to the various agencies is done through the Quality Management program, i.e. CMS, NCQA, URAC.