Our Preauthorization & Utilization Management program provides the foundation for ICM’s ability to identify, manage and mitigate clinical episodes within the Self Funded programs we manage. 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, allow our team to identify high risk and high cost patients early on.
Through our Preauthorization & Utilization Management program, we are able to provide significant savings by promoting the following interventions:
- Redirection into PPO
- Negotiating with vendors
- Avoidance of unnecessary hospital stays
- Appropriate and Timely Discharge Planning through concurrent review
- Denial of requested services if they are not medically necessary or are a plan exclusion
Our standard Utilization Review services include the following core deliverables:
- Preauthorization for inpatient and outpatient surgery
- Vendor negotiations
- Mental health and chemical dependency review
- Concurrent review
- Discharge planning
- Home healthcare review
- Skilled nursing review
- Case management referral
- Reconsiderations and appeals
- Redirection into PPO
- Second Surgical Opinion
How it works: 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 customizable parameters 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 a Utilization Management Nurse. Our Utilization Management Nurses 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 or fax 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 turnaround time well below industry standards, 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. We are extremely well known and respected by Medical Providers and Hospitals as an efficient, friendly, and professional organization; this respect promotes a collaborative, rather than confrontational, oversight of our mutual members’ care.
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 nurses with extensive backgrounds in the health care industry and focused experience in Utilization Management. Also, the members of our Precertification department undergo extensive training in customer service, medical terminology, and our proprietary database. Additionally, the department supervisor reviews all pre-authorizations, every day, to assure that the highest care and attention are given throughout the process.