The Evolution of Utilization Management
Medical Director
As medical director of Alicare Medical Management (AMM), one of my primary responsibilities is to oversee AMM’s Utilization Management (UM) Program. UM has been traditionally focused on providing medical oversight in such a way as to promote optimal outcomes through the appropriate utilization of medical resources. AMM’s UM Program includes hospital and medical pre-certification, concurrent and retrospective reviews, and discharge planning -- among other services.
During the rise of managed care in the 1980’s, some utilization review (UR) organizations earned a less than stellar reputation for denying care based upon subjective review criteria and other questionable practices. This led to the proliferation of state legislation in the 1990’s and the rise of URAC1 as an independent accreditation agency to promote more equitable and evidence-based workflow processes when medical necessity decisions are being made by health plans or their subcontractors. Among other requirements, these regulatory and accreditation requirements added a more structured and transparent appeals process for patients and attending providers who believe that a denial of service was inappropriate.
During the past 20 years, a lot of change has taken place in addition to empowering third-party oversight of what is now called Utilization Management or UM. As a result, UM now is much more than just rendering a certification or denial decision.
Today, UM Programs that are offered through companies like AMM are part of a larger integrated care management system and platform. As a result, medical necessity determinations often are made within a larger package of medical management services and interventions geared towards optimizing clinical and financial outcomes for the patients, their providers and the health plan sponsors. Patient safety and consumer protection also have become a primary goal and value. For example, both internal and external appeal processes are now offered when non-coverage determinations are made. Accredited UM organizations also must maintain two on-going quality improvement projects – one of which must be consumer focused.
Over the coming several years, UM Programs will need to continue to evolve to keep pace with new requirements stemming from healthcare reforms, the continued evolution of evidence-based guidelines, medical and technical innovations, and so on. As part of this discovery process, AMM will continue to embrace the very best attributes of the UM process while it continues to innovate and identify even better tools and procedures for future use.
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