{"id":660,"date":"2020-07-16T19:56:32","date_gmt":"2020-07-16T19:56:32","guid":{"rendered":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/?p=660"},"modified":"2022-08-23T14:46:34","modified_gmt":"2022-08-23T14:46:34","slug":"todays-value-based-care-models-introduce-new-demands-on-utilization-management","status":"publish","type":"post","link":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/todays-value-based-care-models-introduce-new-demands-on-utilization-management\/","title":{"rendered":"Today\u2019s Value-Based Care Models Introduce New Demands on Utilization Management"},"content":{"rendered":"\n<figure class=\"wp-block-image size-large\"><img loading=\"lazy\" decoding=\"async\" width=\"800\" height=\"533\" src=\"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-content\/uploads\/sites\/2\/2020\/07\/Utilizaton-management.jpeg\" alt=\"A doctor and a man in a suit having a discussion over a computer screen in an office\" class=\"wp-image-661\" srcset=\"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-content\/uploads\/sites\/2\/2020\/07\/Utilizaton-management.jpeg 800w, https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-content\/uploads\/sites\/2\/2020\/07\/Utilizaton-management-300x200.jpeg 300w, https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-content\/uploads\/sites\/2\/2020\/07\/Utilizaton-management-768x512.jpeg 768w\" sizes=\"(max-width: 800px) 100vw, 800px\" \/><\/figure>\n\n\n\n<p class=\"leading\">Utilization management (UM) has proven to be an\nextremely valuable tool for facilitating prudent medical consumption. When\nfirst introduced in the late 1980s at which time fee-for-service models\ndominated, UM was primarily regarded as a cost-cutting tool. It has since come\nto be viewed as a means for ensuring the medical necessity of various\nprocedures and treatment using evidence based standards.&nbsp; There has, however, been yet another shift\nthat has come with today\u2019s value-based healthcare models. They emphasize UM\u2019s\nrole in managing costs, as well as helping to ensure the quality of healthcare,\nwhile containing risks. UM is also being deployed as a strategy for supporting\nkey population health management initiatives. All of these added aspects of UM\nalso come with some new requirements.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">Regulatory Changes and Compliance<\/h2>\n\n\n\n<p>Under the Centers for Medicare and Medicaid Services\n(CMS), health insurers must leverage UM to access various services. These\ninclude: care coordination, prior authorization for pharmacy and evidence of\nquality relating to patient care at the right time, right setting and\nresponsive to an individual patient\u2019s needs. &nbsp;When timeframes for prior authorizations are\nnot met, compliance issues can develop placing plans at risk for penalties.<\/p>\n\n\n\n<h2 class=\"wp-block-heading\">NCQA Compliance<\/h2>\n\n\n\n<p>Beyond the CMS standards are yet a higher level of\ncompliance guidelines for healthcare insurers and other organizations to\nfollow. They are the National Committee for Quality Assurance (NCQA)\nUtilization Management Accreditation Standards. Specifically, the NCQA requires\nhealth plans to:<\/p>\n\n\n\n<ul><li>Leverage fair and timely utilization\nevaluations reflecting evidence-based criteria,<\/li><li>Collect and apply relevant clinical\ninformation to make UM decisions,<\/li><li>Ensure that qualified health professionals\nare making assessments of requests and UM decisions, and<\/li><li>Support and align UM decisions with state\nrequirements.<\/li><\/ul>\n\n\n\n<p>To ensure\ncompliance and best UM practices, health plans are advised to closely monitor\ntheir UM practices for any breaches and\/or inconsistencies with both CMS\nrequirements and NCQA standards. They should be particularly mindful of\nefficient processing of prior authorizations. An experienced UM service\nprovider can serve as a valuable partner in helping organizations meet these\nstandards. Seek a UM service provider that employs an experience team of\nregistered nurses and physicians overseeing the full range of clinical services\nand setting including specialty programs. Among the other criteria to seek in a\nUM service provider is its availability on a 24-hour basis and it being\nAccredited to URAC standards.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>Utilization management (UM) has proven to be an extremely valuable tool for facilitating prudent medical consumption. When first introduced in the late 1980s at which time fee-for-service models dominated, UM was primarily regarded as a cost-cutting tool. It has since come to be viewed as a means for ensuring the medical necessity of various procedures&#8230;<\/p>\n","protected":false},"author":1,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_acf_changed":false,"_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[14],"tags":[],"acf":[],"aioseo_notices":[],"_links":{"self":[{"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/posts\/660"}],"collection":[{"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/comments?post=660"}],"version-history":[{"count":2,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/posts\/660\/revisions"}],"predecessor-version":[{"id":999,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/posts\/660\/revisions\/999"}],"wp:attachment":[{"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/media?parent=660"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/categories?post=660"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/www.amalgamatedbenefits.com\/amalgamated-medical-care-management\/wp-json\/wp\/v2\/tags?post=660"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}