ACM

Utilization Management (UM)

• What services are provided as part of Utilization Management (UM)?

  • Precertification
  • Optimal length of stay determination 
  • Concurrent review 
  • Discharge planning 
  • Early Care Management identification 
  • PPO channeling

• What is the goal of UM? Isn't it just more "insurance red tape?"

  The key to a successful medical management program is early identification and action. UM provides the best tool for the initial identification of a patient’s entry into the health care system. This allows the ACM medical management staff to be proactive in working with patients and their providers to assure delivery of health care in the most appropriate and cost effective manner.

• If few services are non-certified, then how does UM reduce overall health care costs for the employer and insured?

  Due to the Sentinel Effect (monitoring causes appropriate behavior), there are few services which are actually non-certified. While reviewing medical services for appropriateness is clearly part of the UM process, early identification of potentially high cost cases is the key to reducing costs. Early identification allows ACM to work directly with the patient and the provider to ensure that care is being delivered in the most appropriate and cost-effective setting. UM impacts care and costs in many ways, including: direction to an in-network PPO provider (PPO Channeling); determining the optimal length of stay, avoiding unnecessary hospital days; concurrent review; collaborative discharge planning with both the patient and provider to ensure that all the patient’s healthcare needs are in place, thereby avoiding delays in discharge and/or a readmission; and initial identification of case management opportunities - naming only a few.

• How does UM reduce overall health care costs for the employer and insured?

  Early identification allows ACM to work directly with the patient and the provider to assure that the care is being delivered in the most appropriate and cost effective setting. UM impacts care and costs in many ways including:

  • Direction to an in-network PPO provider (PPO Channeling)
  • Determining the optimal length of stay (Milliman Care Guidelines), avoiding unnecessary hospital days
  • Concurrent review
  • Collaborative discharge planning with both the patient and provider to assure that all the patient’s health care needs are in place thereby avoiding delays in discharge and/or a readmission
  • Initial identification of Case Management opportunities

• What services do you recommend be Precertified?

  ACM recommends that all inpatient admissions, outpatient surgeries and high cost outpatient services (i.e. infusion therapies; chemotherapy; radiation treatments; PET Scans; MRI; etc.) be precertified.

• Why does ACM recommend Precertification for outpatient services?

  Due to advancements in medicine and the delivery of health care, many very complex and expensive treatments are now done in an outpatient setting. Precertification of outpatient services allows ACM an opportunity to impact health care costs prior to receipt of the claim when the opportunity for proactive involvement has been lost.