What are the most effective ways to evaluate utilization management and review programs?

Utilization management and review (UMR) programs are essential for ensuring the quality, appropriateness, and efficiency of health care services. UMR programs involve assessing the medical necessity, clinical effectiveness, and cost-effectiveness of various interventions and treatments. As a case manager, you need to know how to evaluate the performance and outcomes of UMR programs to improve your practice and optimize patient care. In this article, we will discuss some of the most effective ways to evaluate UMR programs and how they can benefit you and your clients.

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1 Define your goals and indicators

The first step in evaluating UMR programs is to define your goals and indicators. Consider what you are hoping to achieve and what realistic, measurable outcomes you want to see. Additionally, think about how you will measure and track them. Common goals and indicators for UMR programs include reducing hospitalizations, readmissions, and emergency department visits; improving patient satisfaction, adherence, and quality of life; enhancing care coordination, communication, and collaboration among providers; and saving costs and resources. It is important to align your goals and indicators with the standards and guidelines of your organization, profession, and accreditation bodies. Involvement of stakeholders such as patients, providers, payers, and regulators is also key for relevance and buy-in.

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Jaime Dickinson

Director of operations, Always compassionate health, Rochester
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Utilization management and case management go hand in hand in the insurance industry. Utilization determines the clients benefit distribution while the CM can advocate for the benefits for the clients. Utilization management relies on case management to mitigate the cost as well as coordinate benefits that may not be typical of the plan. Another benefit is the collaboration between both for the benefit of the patient while maintaining costs.

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2 Collect and analyze data

The next step in evaluating UMR programs is to collect and analyze data. Data is the evidence that shows whether your UMR programs are working or not. You need to collect data from various sources, such as medical records, claims, surveys, interviews, audits, and reports. You should use reliable and valid tools and methods to collect data that are accurate, consistent, and comprehensive. You should also ensure that you protect the privacy and confidentiality of your data sources.

Once you have collected data, you need to analyze them to identify patterns, trends, gaps, and opportunities. You should use appropriate statistical and qualitative techniques to analyze data that are relevant, meaningful, and actionable. You should also compare your data with benchmarks, standards, and best practices to assess your performance and progress.

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Jaime Dickinson

Director of operations, Always compassionate health, Rochester
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Data is your best friend in determining ROI, quality and future goals for the programs. Analyzation of data is tricky, as there are many variables outside of just the data to consider. This is where individuals with medical background are the game changer. These individuals understand the clinical implications while being mindful of the bottom line. It also assists in contributing to future growth, risk mitigation and potential issues that may arise. The greater the visibility the organization has about "what is under the hood" the better they are able to prepare and stay ahead of the curve.

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3 Implement and monitor changes

The final step in evaluating UMR programs is to implement and monitor changes. Based on your data analysis, you should identify the strengths and weaknesses of your UMR programs and determine the areas that need improvement or modification. You should develop and execute action plans that address the root causes of the problems and leverage the best practices of the solutions. You should also communicate and collaborate with your stakeholders to ensure their support and feedback.

As you implement changes, you need to monitor their impact and effectiveness. You should continue to collect and analyze data to measure the outcomes and results of your changes. You should also review and revise your goals and indicators as needed to reflect your current situation and expectations. By implementing and monitoring changes, you can ensure the continuous improvement and quality of your UMR programs.

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Jaime Dickinson

Director of operations, Always compassionate health, Rochester
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I cannot say I agree with the article with this opinion. Utilization management does not integrate with clients, that is the job of case management. UM has strict guidelines that they do not speak to the clients. This is related to not wanting the clients contacting UM directly when there is an issue with their benefit. The activities that are described are that of case management.

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4 Here’s what else to consider

This is a space to share examples, stories, or insights that don’t fit into any of the previous sections. What else would you like to add?

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Jaime Dickinson

Director of operations, Always compassionate health, Rochester
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Utilization management is one of the most important aspects for insurance companies. They regulate services that clients need but determine if they are necessary. While many do not like managed care this contains the overuse of services by doctor shopping, and ED use. It also prevents unnecessary services from being rendered or a potential duplication of services. This is why UM is important, as without the checks and balances our healthcare would be bankrupt. For example, NYS Medicaid spending had gone unchecked a number of years while increasing the deficit. As Medicaid reform started occurring with managed care the costs are more containable.

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What are the most effective ways to evaluate utilization management and review programs?

1

2

3

4

1 Define your goals and indicators

2 Collect and analyze data

3 Implement and monitor changes

4 Here’s what else to consider

Case Management

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What are the most effective ways to evaluate utilization management and review programs?

1

2

3

4

1 Define your goals and indicators

2 Collect and analyze data

3 Implement and monitor changes

4 Here’s what else to consider

Case Management

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