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:

• Services are predictable – MLTSS in a unique model of care where the services that a member will utilize are known in advance of services being provided. For instance, a member who is authorized for 20 hours of care per week will have limited variability on a weekly basis.
• Service cost is predictable – The cost of providing personal care or other supports and services are often specified by the state Medicaid agency or are contracted by the health plan. A clear picture of cost can be predicted by combining known hours and known hourly costs.
• Authorized services are difficult to change – Health outcomes of the Medicaid member is core to MLTSS programs. Medicaid agencies have implemented stringent appeal processes to protect a member’s right for adequate care. This means it is best to catch utilization issues prior to the start of services.

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. 

• Calculate utilization at the population level – Population-wide average utilization is ultimately the metric that impacts a plan’s financial operations. Understanding how reimbursement and service costs are trending is vital to maintaining an acceptable Medical Loss Ratio (MLR).
• Calculate utilization at the member level – In order to improve utilization operationally, reimbursement and cost needs to be brought down to the member level. Plans can implement software with service guidelines to identify over-authorized or duplicative services.
• Identify members for Utilization Management focus – Health plans can identify members where service costs are exceeding the capitation payment once reimbursement and cost data are linked. These members can be reviewed for appropriateness of service plans and quality interventions can be implemented to improve utilization for high-cost chronic conditions.
• Invest in systems for Utilization Management – Manual or spreadsheet-based systems create an administrative burden. Implementing an IT system reduces the administrative burden, enables staff to focus on the most important issues, and creates a process where problems can be resolved quickly.

​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:

• Timelines. Plans and providers are judged on the how long it takes a member to be assessed. Whether it is a quality measure from CMS, a state regulatory agency, or a health plan rating system, timeliness matters. This can create an incentive to get the assessment done so that larger penalties are not incurred.
• Number of questions. The number of questions in an assessment process can be upwards of 500 when considering all of the questions asked across eligibility screens, level of care assessments, functional assessments and heath risk assessments. There are substantial opportunities for error when a nurse needs to achieve mastery on that many questions.
• Interdependency of questions. Comprehensive assessments cover at least the nine (9) core elements as defined by CMS (i.e. ADL, Cognitive Functioning, Living Arrangement, Current Medications, Mental Health Status, Caregiver Support, Acute and Chronic Conditions, Home Safety, and Provider.) Each of these questions may have implications on how another is answered - they aren't always mutually exclusive. Without a thorough review of the various relationships between 500 questions, an error is likely to occur.

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Ways to improve accuracy

• Internal review. Organizations have created nurse review teams or assessment managers that manually review each assessment for potential errors and issues with consistency. While a "second set of eyes" is better than no review, there is still opportunity for error due to tight timelines, a high volume of questions, and potentially missed interdependencies. While internal review is helpful, it is costly to review 100% of assessments.
• Third-party audit. Some organizations or regulatory agencies implement third-party audit. Most often, this occurs when the assessment data is used to make monetary decisions: whether it is reimbursement from an agency or prior authorization from a health plan. If the process remains manual, the cost of review and audit has simply shifted from one party to another.
• Use technology to support review​. Plans and providers can utilize healthcare IT to improve the effectiveness and cost efficiency of their review processes. Digitizing data, reviewing it for obvious errors, and flagging potential areas of an assessment for nurse assessors to review and document further is an optimal approach. This process can identify potential errors with interdependent questions, improve documentation of unique cases, and provide value-add review at scale.

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.