What is utilization management? 

Utilization management manages healthcare resources effectively and efficiently. It involves reviewing medical treatment plans, care coordination, and implementing evidence-based guidelines and criteria to support clinical decision-making. 

Effective utilization management focuses on connecting patients within the healthcare network, managing transitions between facilities, and assessing gaps in care to ensure patient needs are met. This helps patients receive appropriate care and intervene in quality and safety. It can also include alerting staff and providers to concerns or patient condition changes and communicating with payor sources to verify coverage.

 

Types of utilization management services

There are three different types of utilization management services, including: 

 

Improving efficiency with utilization management services

Healthcare providers and payers can outsource a variety of utilization management services to third-party vendors, including:

The National Committee for Quality Assurance (NCQA) provides a utilization management framework for implementing industry best practices to ensure clinical decisions are made in the best interest of patients and are not influenced by external factors. By implementing this framework, healthcare organizations can ensure patients receive appropriate and timely care while complying with state regulations.

 

How outsourcing utilization management services benefit companies 

As healthcare providers strive to provide high-quality care, it can be easy to overlook essential support services like utilization management. That's where outsourcing comes in.

Outsourcing utilization management services allows companies to focus on providing top-notch healthcare services to their patients. By entrusting these support services to a team of experts, healthcare providers can rest assured that their patients receive the best care possible.

An efficient utilization management program can also help with end-to-end processes such as:

In addition to allowing companies to focus on their core services, outsourcing utilization management ensures compliance and accountability by helping providers stay up-to-date on the latest regulations and guidelines. 

 

Our utilization management services

At ADEC Healthcare, we assess the medical necessity and appropriateness of services in advance. Our utilization management services help control unnecessary expenses at all steps of the healthcare journey.

Our services include:

 

UTILIZATION MANAGEMENT 

1. Introduction 

2. What is utilization management as it relates to healthcare? 

   1. Utilization management is the process of managing healthcare resources to ensure they are used effectively and efficiently. Healthcare providers and payers can outsource a variety of utilization management services to third-party vendors. 

3. What are general utilization management services? 

   1. Prior Authorization Services: Prior authorization is a process in which healthcare providers must obtain approval from an insurance company before certain medical services are provided to a patient. Outsourcing prior authorization services can help providers expedite the process and ensure that necessary authorizations are obtained quickly.

   2. Concurrent Review: Concurrent review involves evaluating the medical necessity and appropriateness of ongoing treatment or services while a patient is still receiving care. Outsourcing concurrent review can help providers and payers ensure that patients are receiving appropriate care and reduce the risk of overutilization.

   3. Retrospective Review: Retrospective review involves analyzing past medical treatment and services to evaluate the appropriateness and necessity of care. Outsourcing retrospective review services can help providers and payers identify potential areas for improvement in care delivery and reduce the risk of unnecessary utilization.

   4. Case Management: Case management involves coordinating and managing the care of patients with complex medical conditions to ensure they receive appropriate and timely care. Outsourcing case management services can help providers and payers improve patient outcomes and reduce the overall cost of care.

   5. Disease Management: Disease management involves coordinating care and providing support to patients with chronic conditions to help them manage their condition and prevent complications. Outsourcing disease management services can help providers and payers improve patient outcomes and reduce healthcare costs associated with chronic conditions.

   6. Analytics and Reporting: Providers and payers may benefit from advanced analytics and reporting to track performance metrics, identify areas for improvement, and measure the effectiveness of utilization management efforts. Outsourcing utilization management services can provide access to analytical tools and reporting capabilities to support these needs.

4. Why outsourcing utilization management services benefits companies 

   1. Allows companies to focus on their core services while others take care of support

   2. Ensures compliance and accountability 

5. Our risk utilization management services

   1. Transitional Care Management

   2. Outpatient Modality, Pre-Authorization

   3. Denial Management

   4. Acute and Consult Transfer Tracking