Utilization Management

Precertification is the Key

Utilization Management (UM) is the process of determining whether the services delivered or scheduled to be delivered to a patient are medically necessary and appropriate. By using established national medical guidelines, AkesoCare evaluates the medical necessity for hospitalizations and out-patient services, and the appropriateness of the overall treatment plan.

The ACM Difference

UM, and specifically the Precertification process, was developed as one of the earliest forms of "managed care." As time has passed, however, the basic concept of the value of this service has been lost, but not with AkesoCare. The key to successfully managing rising health care costs is early identification of catastrophic cases – and then taking action to manage those cases. AkesoCare uses Precertification as a key tool for this early identification of a patient’s entry into the health care system. This allows AkesoCare medical staff to be proactive in working with both the patient and the providers assuring delivery of health care in the most appropriate and cost-effective manner.

The AkesoCare UM Program Impacts Care and Costs by:

  • Directing to an in-network PPO provider (PPO Channeling)
  • Determining the optimal length of stay (Milliman Care Guidelines)
  • Avoiding unnecessary hospital days
  • Performing concurrent review
  • Collaborative discharge planning with both patient and provider assuring all the patient’s health care needs are in place, avoiding delays in discharge and/or a readmission
  • Early identification of case management opportunities

The Bottom Line

AkesoCare maximizes all aspects of the UM process, having the greatest impact on health care costs while increasing overall patient satisfaction.