This is part 1 of a two part article on how Utilization Management works in Everest. Part 1 covers introduction to the module.
The role of coordinated care is emerging as a major component of US healthcare delivery models, not only as a means of improving quality of care but also for controlling healthcare costs. Our Everest product is designed to support all aspects of the care coordination process, of which Utilization Management (UM) is a key strategy.
During the course of the utilization management process, nurses may deal with a number of different situations such as:
- High dollar health services provided to members
- Extended and sometimes unnecessarily inpatient stays
- Over-utilization of services
- Member reluctance to stop services when they no longer meet medically necessary
- Use of investigational/experimental/off-label treatments
The UM module in the Everest arsenal supports pro-active management of situations like those listed above in a way that yields results for the members, involved health care provider(s) and our clients.
As shown in the screenshot below, care coordinators using Everest can at a glance identify what Utilization Management activities have occurred for a member. Displaying this information in an easy to read format allows users to quickly determine if an authorization already exists for the requested item/service or if it requires opening of a new authorization, avoiding duplicate work and adding to user productivity. The Everest authorization forms are designed to guide the nurse through the utilization management process as well as to collect key pieces of information for reporting on utilization management activities and outcomes.
Historically, utilization management services have been performed in a silo, separate from other care coordination activities such as case management. Everest provides an integrated member record which can be used by all disciplines within a member’s care team. A user’s ability to view claim information for the member, care alerts and risk scores from our Makalu product without leaving Everest offers the clinical user additional pieces of information she likely would not have access to otherwise. Tools in Everest guide the nurse through collection, assessment and evaluation of data that pertains to a member’s services and treatment. It also facilitates the assessment of delivery of healthcare services to determine if patient care is medically necessary, appropriate, and meets recognized standards of care. (Everest can support integration of Milliman and InterQual online criteria guidelines for clients who had licensed these 3rd party products.) This integrated approach helps focus all team members on the same goals, helping to prevent overutilization and duplication of services.
In Everest, the UM module has three distinct authorization types:
- Inpatient Stay Authorization: It is aimed at making the right judgments for patients who request the health services that result in an inpatient stay, whether in a hospital, a Skilled Nursing Facility, an inpatient psychiatric facility, a hospice or a an acute rehabilitation center.
- Service/Procedure Authorization: In the United States, a significant amount of healthcare dollars are spent on unnecessary and over utilized services and procedures. Providers are paid for the services/procedures they do, supporting over-utilization as a means to higher provider income. The Service/Procedure authorization forms in Everest are meant to monitor services and to ensure specific services and procedures meet criteria before they are performed.
- Pharmacy Authorization: High dollar and specialty drugs represent significant cost drivers for clients. For that reason, some clients will require specific medications to be prior approved. This type of authorization allows users to not only approve or decline a medication, but also allows them to periodically monitor its use overtime.
[Thanks to Jo Anne Hunt and Minesh Maharjan for contributing to this article.]
The details of Utilization Management in Everest are discussed in Part 2 of the article.