Utilization Management in Healthcare – How Adanta’ s Approach Helps Our Clients
Submitted by Christy Price, UM Director for The Adanta Group
Healthcare today can be very confusing for most of us. Confusion over coverage, knowing which providers are in network, deductibles and copays are just some of the issues. Adding to this list is that many payers also are starting to require pre-authorization for services. While we may be familiar with pre-authorizations for procedures like invasive surgery, many commercial payers like Medicare replacement plans and Medicaid plans administered by managed care companies are requiring pre-authorizations for routine services, like mental health counseling, case management or therapeutic rehabilitation programs, for example.
For those of us in Kentucky, some of these changes first started to appear back in 2011, when Kentucky transitioned much of its Medicaid program to a Managed Care Organization( MCO) model. Under this system, private MCOs assumed responsibility for administering physical health, behavioral health, and substance use disorder( SUD) services. The reform sought to improve care coordination, enhance accountability, and contain costs. However, it also introduced new administrative and billing complexities for providers, as well as potential barriers to timely service access for patients navigating differing MCO rules and authorization processes.
In response to the challenges and barriers created by these initial changes, The Adanta Group proactively developed a Utilization Management Department to help clients navigate these new requirements and ensure continuity of care within a changing healthcare system. Why This Matters for your care. Choosing a service is only the first step. For most payers, it is not enough for a patient to want a service, there must also be a medical need for it, aka medical necessity. For
many services, medical necessity must be established, and for those patients with Medicaid / MCOs, their health plan must also approve the types and numbers of services that can be provided for that client. Many Medicare replacement plans may now require a referral from a primary care provider before being allowed access to certain behavioral health services.
If you choose behavioral health services, including mental health and / or substance use, Adanta’ s Utilization Management Department can help ensure you get the services you need, allowing you the time to focus on treatment and recovery. The UM Department collaborates with the client’ s treatment team to gather the necessary clinical information to seek approval. If all documentation meets the plan’ s criteria, the service is approved and may be provided. Additional information is often requested to finalize the process. In some cases, a request may be denied, requiring a peer-to-peer review with the insurance plan’ s medical director. If the service remains denied, an appeal can be filed on behalf of the client. As UM staff review requests for services, they evaluate the following areas when working to get services approved:
• Assessment of medical necessity- determining whether a healthcare service or treatment is required for the patient’ s condition.
• Review of care plans – evaluating the appropriateness of proposed treatment and procedures.
• Coordination of care- ensuring patients receive the necessary services from the right providers.
• Monitoring resource utilization – tracking healthcare costs and identifying areas for improvement.
18 • SEKY- Southeast Kentucky Life December 2025