Our Utilization Management team works diligently to ensure that patients receive all the resources they can to receive the best care. We will guide you every step of the way to achieve positive clinical outcomes.

⚬ What it is:

Utilization management (UM) is an integral part in health plans. It was primarily viewed as a cost-containment strategy, but is now moving towards a value-based care model, where reimbursing care clients based on clinical outcomes is leveraged over the quantity of services delivered. It is the evaluation of the medical necessity, appropriateness, and efficiency of the use of health care services, procedures, and facilities under the provisions of the applicable health benefits plan.

⚬ A UM Program that ensures the Right Path to Care

Health plans and members need a solution where the receive the most effective health care services, procedure and facilities are used to provide a pathway to wellness.

⚬ What we do:

Advanced MSO’s Utilization Management Department processes requests for authorizations and coordinates with the clients through the fundamental practice of managed care. We aim to keep referrals within the contracted network. Physician profile referral statistics and hospital bed days reported monthly gives clients a current overview of their UM activities. The Case Manager monitors, tracks, and implements the utilization and quality of patient care process. More importantly, Case Management carefully monitors patients’ status on a daily basis. Advanced MSO’s IPA’s have contracted hospitalists to assist PCPs in inpatient admission, which further enhances the quality and coordination of care to our members.

UM management is based on appropriateness of care and service and existence of coverage. Rewards and incentives do not influence any UM decision making. All denials must be strictly based on insufficient medical appropriateness or not a covered benefit. To assure that the risks of under-utilization are considered, no rewards or incentives can be issued that will discourage appropriate care and services to the members.