A successful UM program is built around highly skilled, experienced clinicians who can see the bigger picture, put quality first, and improve patient care.
FREMONT, CA: People usually think that payers use utilization management (UM) to lower the cost of health care. Even though successful programs do lower claim costs, the main goal of a good UM program is to improve the quality of care. When UM programs focus on denials and put cost savings ahead of patient care, the cost of a claim often goes up by accident. Denying claims to save money can get in the way of early care and lead to more expensive procedures in the future because care is delayed. The key to making UM programs work is to give the proper care to the right patient at the right time.
Following are the best practices for an effective utilization management program in the healthcare sector:
Processes, roles, and rules need to be clearly defined: A well-defined utilization review process, in which each step and the roles and responsibilities of each team member are spelled out, ensures quality, repeatability, and sustainability. The success of a UM program depends on having strong policies and procedures in place. These should cover things like the rules for admissions and requested services, the complete list of professional services offered, and reviews of care settings.
