Utilization management (UM) has proven to be an extremely valuable tool for facilitating prudent medical consumption. When first introduced in the late 1980s at which time fee-for-service models dominated, UM was primarily regarded as a cost-cutting tool. It has since come to be viewed as a means for ensuring the medical necessity of various procedures and treatment using evidence based standards. There has, however, been yet another shift that has come with today’s value-based healthcare models. They emphasize UM’s role in managing costs, as well as helping to ensure the quality of healthcare, while containing risks. UM is also being deployed as a strategy for supporting key population health management initiatives. All of these added aspects of UM also come with some new requirements.
Regulatory Changes and Compliance
Under the Centers for Medicare and Medicaid Services (CMS), health insurers must leverage UM to access various services. These include: care coordination, prior authorization for pharmacy and evidence of quality relating to patient care at the right time, right setting and responsive to an individual patient’s needs. When timeframes for prior authorizations are not met, compliance issues can develop placing plans at risk for penalties.
Beyond the CMS standards are yet a higher level of compliance guidelines for healthcare insurers and other organizations to follow. They are the National Committee for Quality Assurance (NCQA) Utilization Management Accreditation Standards. Specifically, the NCQA requires health plans to:
- Leverage fair and timely utilization evaluations reflecting evidence-based criteria,
- Collect and apply relevant clinical information to make UM decisions,
- Ensure that qualified health professionals are making assessments of requests and UM decisions, and
- Support and align UM decisions with state requirements.
To ensure compliance and best UM practices, health plans are advised to closely monitor their UM practices for any breaches and/or inconsistencies with both CMS requirements and NCQA standards. They should be particularly mindful of efficient processing of prior authorizations. An experienced UM service provider can serve as a valuable partner in helping organizations meet these standards. Seek a UM service provider that employs an experience team of registered nurses and physicians overseeing the full range of clinical services and setting including specialty programs. Among the other criteria to seek in a UM service provider is its availability on a 24-hour basis and it being Accredited to URAC standards.