Why is utilization management (UM) required at all?
Utilization management was implemented to ensure that services provided are medically necessary. Insurance policies and benefit plans usually have language that prohibits coverage for services that are not deemed medically necessary for the treatment of illness or injury. Once a patient reaches maximum medical improvement, the services may no longer be covered. This is sometimes difficult to tell without notes. The average claims examiner is not trained to review or make a determination on medical necessity and most claims do not clearly indicate that the patient is on maintenance care. Unfortunately, over the past twenty years or so, UM has changed from its original form. Today UM is sometimes used to discourage the submission of claims that should be covered. We all know of carriers and networks that require excessive amounts of paperwork to be completed or tell you that your average number of visits per patient is high. I-AHC vision of UM is consistent with the UM described in the f
Related Questions
- Our locality already has Utilization Management (UM) staff, so do I have to terminate this staff person and have the Intensive Care Coordinator perform the utilization management duties?
- What is the difference between clinical criteria, practice guidelines, treatment protocols, clinical practice guidelines, and utilization management (UM) review criteria?
- What are the functions of the Utilization Management (UM) Department?
