How to Develop a Successful Utilization Management Program
Utilization management (UM) helps lower costs and improve outcomes by ensuring members receive the most appropriate care in a timely, cost-effective manner. Initially, UM was primarily focused on reducing excessive use that leads to waste without any measurable gains in quality or outcomes. The focus has now expanded to encompass improving quality and regulatory compliance […]
The Differences between Utilization Management and Case Management
Effective Care Management involves many people with differing roles and responsibilities, collaborating for the benefit and wellbeing of patients/members. Care Management itself is a wide umbrella, which Utilization Management (UM) and Case Management (CM) are both under. Depending on the structure of an organization, UM may be a stand-alone service in partnership with CM, or […]
Improving Patient Care with Coding
The healthcare industry has been no stranger to shortages of qualified workers over the few years, and the coding workforce is no exception to this trend. There is a need for more medical coders across the U.S., making it increasingly more challenging to find skilled and credentialed coders who can execute the specific type of […]
Health Insurance Claims Analysis
A current trend in the Healthcare industry is the increasing volume of inpatient claims denied by payers based on lack of medical necessity. While Medicare offers detailed payer categories compared to other providers, they also reject the highest number of shares. However, from 2021 to 2022, the inpatient claim denial saw a rise of 18.5% […]
Coding Around the Clock (and Around the World!)
By Melanie Kiss-Endicott, MBA/HCM, RHIA, CDIP, CHDA, CPHI, CCS, CCS-P, FAHIMA The demand for experienced, certified medical coders is a constant challenge for healthcare organizations. One solution for this demand is outsourcing medical coding to companies with offshore coders to supplement your current team. Offshoring has several benefits, including cost savings, a highly qualified labor […]
Utilization Management Services Improve Case Handling Time and Reduce Management Cost
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Nations Leading Third Party Administrator
The Key to Effective Utilization Management Better Patient Care Reduced Cost
Utilization management is commonly assumed to be a strategy payers implement to reduce healthcare cost. Although successful UM programs do result in reduced cost of claims, the focus of an effective utilization management program is improved quality of care. When utilization management programs focus on denials – prioritizing cost savings over patient care – they […]
