Utilization Management and the quality behind it
Utilization review is the process of reviewing a service that is to be provided, is being provided or has been provided to determine if that service was medically appropriate and necessary for the patient based on their presentation to the provider of the service and the patient’s ultimate medical outcome. This process is accomplished by a Registered Nurse following InterQual Criteria. The nurse may perform this service telephonically or the nurse responsible for the community of residence of the patient or the hospital may review the case in person. Note: Integrated Plans implements consulting agreements with Registered Nurses in each community where the majority of the employer group’s employees reside. Integrated Healthcare Management is unique in that way and it allows Integrated Plans to ensure better patient engagement and medical outcomes.
Utilization Review will be staffed Monday through Friday from 8:00 AM until 5:00 PM. In addition, a on-call staff member will be available after hours and on weekends to intervene as necessary to assist the providers or members if the need arises. If the Utilization Review nurse is uncomfortable with their findings, those findings are discussed with the Integrated Healthcare Management Medical Director and the patient’s attending physician.
Additional procedures we will provide
In addition to our expected tasks Integrated Plans will individually manage those chronically ill members who do not agree to be assigned to a Patient Centered Medical Home (PCMH) chronic disease management program. As with every chronic disease management program there will be those members who are non-compliant, or for whatever reason refuses to participate in the PCMC chronic disease management program. The Integrated Plans prior authorization team, which includes a Registered Nurse, will track the utilization of these members, intervene when the members requires assistance and take whatever steps necessary to bring the chronically ill patients under control.