We maintain the quality of health services
We maintain a comprehensive utilization management (UM) program that provides a spectrum of services to support population health management, ensure quality care and sustain healthy client populations.
Our UM program supports effective utilization of health services. The misutilization of health services (inappropriate treatment that wasn’t medically necessary or didn’t meet generally accepted standards of care) can adversely affect overall health and well-being. We conduct ongoing data mining and analysis to identify client populations where people’s health care utilization lies outside of the expected norms. This provides us with the group-specific information needed to design corrective interventions targeting individuals, caregivers and providers.
Our UM program supports appropriate delivery of health services. We audit provider treatment patterns through both automated and human monitoring. Provider claims are electronically evaluated through an extensive set of procedure-specific business rules to ensure that services are appropriate and client resources are safeguarded. When medical necessity must be determined, our experienced professional peer reviewers objectively evaluate provider performance by consistently applying sound clinical principles and evidence-based practice guidelines.
Our UM program supports fair and consistent utilization review. We routinely monitor the accuracy and consistency with which our professional peer reviewers apply clinical principles and practice guidelines in their decision making. This ongoing evaluation includes peer reviewer credentialing, formal audits of clinical determinations, regular training and periodic peer reviewer testing. In addition, the clinical review criteria used by our peer reviewers are regularly monitored for conformance with prevailing practice guidelines and treatment norms.