We aim to facilitate patient-informed and cost-efficient care, prioritizing patient and community needs. Furthermore, we:
Ensure UM Model, policies and practices are in alignment with §482.30 Condition of Participation: Utilization Review
Align industry best practices to ensure efficient, effective utilization management processes are in place.
Apply a QI process to improve operations.
Review and ensure the hospital system has in effect a utilization review (UR) plan that provides for review of services furnished by the institution and by members of the medical staff to patients entitled to benefits under the Medicare and Medicaid programs as required by CMS.
Assess and develop the UM Committee
Work with the UM and Denial Committees that must review professional services provided, to determine medical necessity and to promote the most efficient use of available health facilities and services.
Review availability and use of necessary services – underused, overuse, appropriate use.
Review timeliness of scheduling of services – operating room, diagnostic tests and treatments
Align best practices and key performance metrics that demonstrate the quality of your organization’s programs to employers, regulatory agencies, health plans and organizational fiscal measures
Ensure fair and timely utilization evaluations while using your choice of objective, evidence-based medical necessity and level of care criteria.
Collection and use of relevant clinical information to make utilization management decisions.
Ensure your UM team has qualified health professionals assess reviews and make utilization management decisions
Develop orientation, education and training guides in alignment with your UR policies and procedures and daily operations.
Ensure UM workflows, policies and procedures align with state, and third party payer requirements.
Ensure and/or devise a customized denial prevention program, in alignment with revenue cycle, clinical documentation integrity, physician advisors, payers, and other key stakeholders
