Utilization management is not about preventing treatment, but about promoting the cost-effective use of providers and services. Our solution for medical and behavioral utilization management is built on this philosophy, and is a valuable resource to health plans as they deliver care across the continuum.
Our clinicians safeguard against unnecessary procedures and redundant services by closely monitoring for appropriateness throughout care delivery. From pre-service authorizations to concurrent review to retrospective review, our team applies national criteria and guidelines to make determinations. They evaluate all aspects of medical necessity, quality and relevance, instead of relying on diagnostic codes alone, to assure your members are receiving the right care, at the right time, in the right setting.
For ongoing clinical guidance and support, our highly qualified medical directors assure evidence-based practices are adhered to in all determinations. Our board-certified physicians and psychiatrists are also available for physician review, peer-to-peer consultations, and for support with first- and second-level appeals.
We believe that utilization management provides the opportunity to improve care delivery and identify individuals in need of care management. With a real-time referral process and established triggers, we identify and refer members who would benefit from case management, chronic condition management and disease management.
Contact us today to learn more about how our medical and behavioral utilization management can benefit your health plan and its members.