Program Objective
Our Preauthorization & Utilization Management
program is the first step in monitoring and controlling the
way your benefit plan is used. Developed in 1993, this program
enables us to ascertain the medical necessity of the services
a patient may receive, ensure that the treatment is the most
appropriate and cost effective, and most importantly, we are
able to identify high risk and high cost patients early on.
Cost Savings
With our Preauthorization & Utilization
Management program, we are able to provide significant savings
throughout the process by utilizing the following interventions:
-
Redirection into PPO
-
Negotiation with vendors
-
Avoidance of unnecessary hospital
stay
-
Discharge planning through concurrent review
-
Denial of
requested services if they are not medically necessary
or are a plan exclusion
With these services, we are able to ensure that each procedure
is the most cost effective for our client and the patient, while
at the same time making sure that the patient receives a high
level of care. As an example, the chart below displays how our
concurrent review for inpatient hospital stays compare to the
national average.
| |
National Average*
Under Age 65
|
West Coast Average* |
ICM |
Hospital Days
Per 1000 Lives
|
426 |
375 |
158 |
Annual Cost of Hospital Days
per 1000 Lives (At $3500/day)
|
$1,491,000 |
$1,312,500 |
$553,000 |
*Census for Disease Control, 2004 That's an overall savings with ICM of $759,500 to $938,000 per
year!
Program Description
The Preauthorization & Utilization Management
program offers a wide variety of quality, cost-saving services,
such as:
-
Preauthorization for inpatient and outpatient
surgery
-
-
Mental health and chemical dependency
review
-
-
-
-
-
-
Reconsiderations and appeals
-
-
Whenever a patient needs a high cost service,
the provider calls ICM. Our Preauthorization Staff then enters
the patient's demographics, and verifies that the procedure
requires preauthorization according to the guidelines set
by our client. If the procedure requires preauthorization,
the Preauthorization Specialist enters the medical information,
verifies that PPO providers are being utilized, and, if possible,
authorizes the procedure over the phone. If the procedure
is more complex, the Preauthorization Specialist will request
clinical notes to go to our Utilization Management Department.
Our Utilization Management Nurses then use nationally published
criteria to determine if the procedure is medically necessary
and appropriate based on the information provided. If the
procedure is questionable or complex, the information is
then forwarded to the Medical Director for a final determination.
Additionally, hospitalized patients are concurrently reviewed
via telephone throughout their stay. On-site concurrent review
may be done in cases where significantly complex medical
care is occurring and complex discharge planning needs are
identified.
With an average turn around time of 3.5 hours, our team
of trained specialists and certified nurses is able to quickly
and effectively make these determinations, without hindering
the care of the patient. Compared to the Department of Labor
regulation requiring a determination in 15 days, Innovative
Care Management stands out for our speed and efficiency.
The Preauthorization & Utilization Management Team
At Innovative Care Management, we pride ourselves
on superior customer service, efficiency, quick turn-around
time, and accuracy in our determinations; none of this could
be done without the two departments of this program. The Utilization
Management Department consists of 6 RNs, all with CPUR certification,
including a supervisor of the department to oversee the process.
Also, the 8 members of our Precertification department undergo
extensive training in customer service, medical terminology,
and our proprietary database. Additionally, the department
supervisor reviews all preauthorizations, every day, to assure
that the highest care and attention are given throughout the
process.
Contact Us
Call Innovative Care Management to ask our sales department
about the Preauthorization and Utilization Management Program
or our other programs. We're here to help you start saving
while maintaining the highest quality care.
General Contact Information:
Innovative Care Management, Inc.
10117 SE Sunnyside Rd., Box F409
Clackamas, OR 97015
Toll Free: 800-862-3338
Portland Area: 503-654-9447
Fax: 503-654-8570
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