There are many different processes that can be used to determine the necessity, appropriateness, and efficiency of healthcare services. In the managed care model, it is important to have an effective Utilization Management (UM) program because it enables health plans and community organizations to ensure that they are managing the cost of services appropriately as compared to the capitation rate.
Why prospective review in Long Term Services and Supports?
A case-by-case prospective review is the most important type of Utilization Management process within the MLTSS setting of care for several reasons:
Key Strategies for Implementing Utilization Management
The strength of a organization's analytical capabilities directly translates to the success of their Utilization Management program and financial results.
Financial risk is the burden of health plans in Managed Long-Term Services and Supports. Leveraging technology to implement a prospective Utilization Management program, at the member-level, is a critical initiative to help achieve improved per capita service cost while maintaining positive health outcomes.