Expert Insight
Medical management
How utilization management drives patients
to the right kind of health care
T
he Institute of Medicine estimated
30 percent of health care spending
in 2009 was wasted. Patients
got duplicate services, unneeded
services or services that haven’t proven to have
medical value. Medical management can help.
Utilization management enables health plan
members and network providers to contact
a benefits manager to determine whether
services are medically necessary, says Dr. Robert
Sorrenti, medical director at HealthLink.
Years ago, physicians, hospitals and
providers strongly opposed utilization
management, feeling it intruded upon their
ability to make decisions. Today, there is
acceptance, along with strong interest from
those paying for health plans.
“I can’t say providers embrace it and love
it, but people accept this as a tool to help
manage some of the utilization,” says Sorrenti.
Here are some utilization management
services to manage unnecessary clinical
procedures.
What’s the benefit of
utilization management
services?
Utilization management moves people to
getting the right quality of care at the right
time through evidence-based medicine.
If you don’t medically need a service, you
shouldn’t get it. CAT scans involve radiation,
one MRI can lead to another and certain
procedures with unproven outcomes can
be deleterious.
The bottom line is that managing
expensive and sometimes unnecessary
services results in less expensive health care
for employers and health plan members. As
plan sponsors, employers have a renewed
interest in medical management, particularly
those struggling to keep pace with health
insurance cost increases. They are looking for
ways to control that without shifting all cost
back to their members.
How does utilization
management determine
what is, or isn’t, medically
necessary?
Health benefits managers employ an
extensive process to determine if a service
is medically necessary. They utilize medical
policy and clinical guidelines to determine
the appropriate rationale for carrying out a
procedure or service, or using a particular
drug. Then they match each member’s
situation with policies and guidelines to see if
the service makes sense.
8 •The Link
Is time a factor?
No. Emergent procedures aren’t reviewed, and
with elective procedures, there is time for due
diligence. Accredited utilization managers
have reasonable turnaround times — usually
no more than three days — to get back to
providers and members.
What services are typically
reviewed?
In-patient days are reviewed to ensure patients
are moved through the continuum of care. You
don’t want them in the hospital for $5,000
per day, waiting for a bed in a skilled nursing
facility, where the cost is $1,000 per day.
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