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.
When it comes to home care, there is no shortage of assessments that capture a member's needs. These assessments can come in a variety of forms (e.g., eligibility screens, level of care assessments, uniform comprehensive assessments, functional tasking assessments, etc.) It's high stakes for Managed Care Organizations and HCBS providers to complete accurate assessments in order to equitably identify member needs, improve health outcomes, and maintain financial viability in an industry with narrow margins. Let's explore some of the reasons for errors and options to improve accuracy:
Common causes of error
The process of assessing an MLTSS member is complex and requires sound professional nursing judgement. However, there are several challenges in the implementation of assessment systems that make a nurse's job harder:
Ways to improve accuracy
Our clients use our products to apply review logic to each assessment in a matter of seconds which would otherwise require manual effort that is prone to error. This helps plans and providers achieve the aim of a comprehensive assessment system: to consistently and accurately assess members so that appropriate individualized care can be provided.