Even though employer sponsored health insurance plans will always incur claims that are unexpected, there is substantial evidence to show that many of the events that are reimbursable by a health care benefit plan are both controllable and preventable by continuous utilization management.
Continuous utilization management is an integral part of care management and requires a approach beyond the typical. It ensures the delivery of quality health services in a timely, medically appropriate and cost efficient manner any time and every time for your employee population.
Typical utilization review starts when the employee or their family members need a medical service. This is a reactive approach and only achieves limited goals. Continuos utilization management requires regular monitoring and communication with employees as well as your providers to elevate and improve delivery of health care and improve outcomes.
It starts with establishing trust with the employee. Employees should feel comfortable knowing that your decisions will be based on ensuring the appropriate care and services for them and you have no financial incentives to deny services.
The process should include a number of services including education, arranging routine preventative check-ups or regular telephone follow-ups, to ensure that the member is following the plan of care properly. This approach helps members learn how to better manage their own conditions, becoming active participants in maintaining good health.
For employees with certain acute or chronic conditions, the process should help connect employees to evidence based disease management programs educating them on nutrition, physical activity and medication adherence.
On an ongoing basis, the care and utilization team should evaluate each employee’s treatment plan and the need for inpatient, outpatient or remote care. This may require working closely with their primary care doctors as well.
When a medical service is required, the team should carefully review the eligibility of the employee, benefit coverage, the desired place of service, in/out network status of the provider, medical appropriateness of the service, co-morbidities and complications, psychosocial situation and other necessary factors to address employee’s specific needs.
If a surgery is required, the team should engage the member prior to admission and help her with an increased level of comfort to eliminate potential barriers to discharge. A medical expert in utilization team should contact the provider to discuss the treatment plan. This process can be quite effective in eliminating unnecessary surgery and procedures, is less imposing on the patient, and avoids redundant examination costs.
In the inpatient setting, the process should ensure that doctor orders are carried out in an efficient and accurate manner, anticipate treatment, plan ahead and continually monitor the patient’s progress and facilitate discharge planning.