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 with national care recommendations, which includes addressing underutilization.
“UM programs are part of the delicate ecology in health care delivery, wherein the program offers to seek to deliver the right care to the right patient at the right time.”
The primary responsibility of optimal utilization typically depends on UM nurses, whose job it is to track service intake, identify insurance coverage, determine medical necessity, and secure final approval. Provider organizations struggling with nursing shortages can experience challenges in patient safety, care quality, and care delays that can lead to over- or underutilization. The impact of nursing shortages on physicians, many of whom are already struggling with long hours and clinical burnout, can exacerbate these challenges.
The bottom line is that the need for UM is greater and more challenging than ever. The following guidelines can help organizations develop a successful UM program in these difficult times.
· Develop standard UM processes, including responsibilities and policies. Each organization is unique and has unique challenges, which is why it’s necessary to identify specific roles within their UM teams based on the organization’s member population, services, and care settings. Particular attention should be paid when establishing and communicating responsibilities and expectations for each member.
Along with roles, organizations must implement processes and policies to ensure regulatory compliance and acceptable standards of care. These should include clearly defined guidelines for admissions and requested services, professional service offerings, and care-setting reviews. Each member of the UM team should be educated about these topics to ensure they understand why each is vital to appropriate care utilization, outcomes, cost containment, and member experiences.
· Utilization review program with physician oversight. Review accuracy is at the heart of an effective UM program, which is why organizations must employ the help of a dedicated, experienced clinician—preferably a physician—to oversee the entire review program. This includes overseeing the UM team members conducting the review. This should include providing best practices and guidance around standards of care specific to nursing staff and their respective fields and care settings.
The most effective UM advisor is someone who displays a high degree of critical thinking and creative problem-solving skills, both of which are essential for successful decision-making. Organizations should choose someone who has a deep understanding of all acceptable clinical care standards, as well as the legal and financial implications of how and when that care is delivered.
· Quality and process improvement. Quality improvement is at the core of a successful UM program. Therefore, audits, ongoing clinical monitoring, and provider evaluation are critical. Site visits and medical record reviews can also be helpful. The information gleaned from these audits can help identify problematic patterns and opportunities for improvement. Member satisfaction surveys should also be utilized as they can be a valuable tool in identifying areas of concern. Quality improvement efforts should include regular monitoring of patient grievances and the timeliness of responses.
A quality improvement program should also include coaching for UM staff and ongoing provider education. Educational materials should be customized based on quality audit insights. To be most effective, coaching and training should include reviews of actual findings so staff and providers can better understand how their roles impact outcomes and costs.
In Pursuit of the Quadruple Aim
An effective UM program is essential for achieving the Quadruple Aim of the right care, at the right time, in the right setting, and the right cost. All result in improved outcomes, lower costs and better experiences. Implementing a well-organized and effective UM program enables payers and providers to work together in an innovative way to elevate the equality of care while lowering costs for all. Shearwater Health can help.
Shearwater Health provides utilization management solutions with more than 3,000 experienced clinicians and over 20 years of experience in healthcare. Shearwater Health’s dedicated clinical teams deliver improved quality of care, reduced cost, and more effective clinical processes to eight of the top ten payers in the industry.
With 98.9% standard quality audits, 97% clinical decision accuracy, and URAC accreditation, coupled with an average 30-65% savings on direct labor costs, Shearwater Health can help payer organizations implement, scale, and manage a successful utilization program.
Contact us today to find out what a utilization management partnership with Shearwater Health can do for your organization.
