Simply Business

In a Value-Based Setting, Where Does Utilization Management Stand?

Interior of a modern medical laboratoryHealth care benefits providers and payers must work together to guarantee the quality and efficiency of care provided. Health care benefits must be dependent on value. To ensure that, utilization review managers use an approach called preauthorization. Industry experts from Case Management Innovations answer common questions about utilization management (UM).

Q: What is traditional UM?

A: Traditional utilization management is when a provider asks the payer to get authorization in advance. They need it to continue to use the special drug or to go ahead with the surgery. This is an extremely manual procedure as it needs plenty of paperwork documentation.

This is an expensive process for both providers and payers due to the amount of administrative work required. It may be tedious, but it’s necessary to maintain the quality and proper use of health care services.

Q: Is there an alternative?

A: The medical field is looking into improving UM with the use of technology. This includes integrating a clinical decision support software. What this does is retrieve information directly from a patient’s electronic health record. They will then run this data using a payer-designed algorithm. Otherwise, this advancement could also probe the clinician a set of questions.

They then have to check if the patient’s data meets their particular qualifications. If so, the software would instantly and automatically approve the process. Complicated cases, however, would still require a manual review.

The downside to using software for UM, though, is that patient data still needs the expertise of an experienced reviewer.

Although technology advancements are inherently good, much research still needs to be done to perfectly execute functions such as evaluations and approvals. There are plenty of companies that offer remote utilization management review services, most come at an affordable price.