Utilization management is a proactive approach to controlling utilization and cost before and while service occurs. Without debating the success or failure of "managed care", it is nonetheless a reality in behavioral health care. The goal of utilization management is to provide the 'right' amount of care for the 'right' length of time in order to address specific behavioral health needs and strengths; that is, "No more, but no less" than what is indicated. Utilization management is driven by clear criteria for admission, continuing care, discharge, and for each level and type of intervention. Success is measured by a number of outcome indicators, including the cost of care.
Utilization management is of particular importance to a managed care organization when they have a fee for service contract with a provider. Conversely, it is a priority with the provider when they are at risk in a capitated or case rate contract.
The most cost-effective way to implement utilization management is through automation.
To be effective, a UM system must be integrated with the clinical applications including client registration, quality assurance, treatment plans, service notes, assessments, billing and scheduling. The billing software maintains the contract and benefit information, which should be accessible while in the scheduling software. The standard treatment protocols, if available, should also be on-line.
Currently there is disagreement concerning whether payer's criteria for medical necessity should be made available to the providers. Some MCOs have published protocols specifically for their provider network, while others keep it a guarded secret. Without a clear set of standards for defining what services are appropriate for a particular diagnosis, it is more difficult to develop a utilization management system. In this scenario, a denial management system can be of benefit to the provider. If these criteria are not available, payer and service to determine the utilization criteria employed can analyze the actual claims and denials.
Some characteristics of a good UM system include the ability to build utilization criteria for specific payers and plans, and to cross reference the patient's claims data with the payer files. In some more sophisticated systems, utilization management decision trees are incorporated into the software that assist an intake professional or case manager in placing the patient or in reviewing the services that have been delivered.
The benefits of an automated utilization management system include an improvement in accuracy of claims, consistency, efficiency, speed, impartiality, flexibility and timeliness
About The Authors:
Bruce Johnson, M.S., is President of Johnson Consulting Services, Inc., an information management consulting firm that specializes in working with healthcare, social service and managed care organizations. He can be reached at (800) 988-0934, www.jcsconsultants.com or by e-mail at jcs@eos.net. Mr. Schafer is a clinical records and operations management consultant. He specializes in working with managed care, behvavioral healthcare and child welfare organizations. He can be reached at (800) 661-2435, www.schaferconsulting.com or by e-mail at steve@schaferconsulting.com.
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