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Utilization Management

Utilization Management Department encompasses three main areas: outpatient review, inpatient review, and case management (described in more detail; see below). Essentially, the utilization management umbrella is designed to ensure consistent care delivery by encouraging high quality of care in the most appropriate setting from our highly qualified provider network. The patient’s clinical information is collected to determine the level of care needed and that the proposed treatment is medically necessary. Members of the health care team follow the patient throughout the healthcare delivery system and ensure that appropriate facilities and resources are utilized.

Authorization Auto Approval

  • Built application for auto approval of authorization based on various UM guidelines (including LCDs, NCDs, various health plan medical necessity guidelines).

  • Expertise in fax form and web portal development to facilitate auto approvals.

Authorizations Workflow System

  • Developed workflow systems for authorization processing. 

  • Capable of handling large volume(>5,000 per day) of authorization reviews manually or automatically along with document management.

  • Flexibility to define and alter workflow and validation rules based on company or line of business or service type or other factors.

  • Allows for easy reporting of all events (auto captured) related to authorization processing and ensuring timeliness.

Super Authorizations

  • Designed scripts to group multiple authorization created in one episode of case to ensure smooth claims matching in various situation.

  •  Designed ways to match more than one claim based on same authorization while avoiding duplicate payment.

Post Decision Automation

Adept in handling peer to peers, reconsiderations, appeals and any other post decision activity from a systems, compliance and process point of view.

Why Choose Our Utilization Management Services?

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Enhanced Patient Outcomes

Our proactive approach improves recovery times and overall patient satisfaction.

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Cost Efficiency

By preventing unnecessary treatments and hospitalizations, we help manage costs without compromising care quality.

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Compliance Assurance

We ensure that all care provided adheres to medical guidelines, payer policies, and regulatory requirements.

How Utilization Management Works

02

Clinical Documentation Review

  • Review submitted diagnoses and detailed treatment history

  • Evaluate proposed treatment plan and expected outcomes

03

Medical Necessity Evaluation

  • Compare request against evidence-based clinical guidelines

  • Assess appropriateness of care setting and treatment alternatives

01

Benefit Verification

  • Verify patient's current insurance coverage and plan benefits

  • Check remaining benefit allowances and plan-specific requirements

04

Authorization Decision Process

  • Conduct initial clinical review against standard criteria

  • Issue approval or escalate to physician review if needed

06

Care Management Integration

  • Coordinate transitions between providers and care settings

  • Ensure proper follow-up care and support arrangements

05

Utilization Monitoring

  • Track authorized vs delivered services in real-time

  • Monitor for appropriate service levels and identify usage patterns

07

Quality Review & Program Assessment

  • Analyze authorization patterns and denial/appeal rates

  • Assess program effectiveness and identify improvements needed

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