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EXTERNAL PROVIDERS

 

Utilization Management

 
Introduction   Resources
 

Introduction

This section addresses Facey Utilization Management (UM) processes and the integration of Facey Case Management (CM) services for our Managed Care patients.

UM is a process to assure the delivery of medically necessary, optimally achievable, quality patient care through appropriate utilization of resources in a cost effective and timely manner.  UM evaluates medical necessity, medical appropriateness and efficient use of medical services, procedures and facilities, including specialty care, inpatient, outpatient, home care, skilled nursing services, ancillary services and pharmaceutical services.  All UM functions are performed under the direction of the UM Department.

Requests for services submitted by providers are reviewed by UM using Facey Medical Group clinical guidelines, Milliman Care Guidelines, Health Plan guidelines, and other criteria as approved by the Facey Medical Guidelines Committee, National Guideline Clearing House, ICSE ICSI (Institute Clinical System Integration, www.icsi.org), Up-to-date, the Agency for Healthcare Research and Quality, NIH Consensus Statements, authoritative text books and journals, and Medicare Coverage Guidelines.  Decision criteria for medical and behavioral health services are reviewed and approved annually by the UM Committee and as necessary additional criteria are adopted by the UM Committee throughout the year.  Criteria are utilized on an individual case-by-case basis taking into account patient need and characteristics of the delivery system.  Criteria are applied with consideration for the individual patient’s needs, which include but may not be limited to: age, co-morbidity, complications, progress of treatment, psychosocial situation and/or home environment.  Facey Medical Foundation uses board certified consultants as necessary to assist in making medical necessity decisions.  Requesting providers are notified of the decision via written correspondence.  Criteria for appropriateness of medical services are clearly documented and available upon request.  They are distributed via provider newsletters.  Providers may request copies of the criteria used to make a decision by calling Facey Medical Foundation’s UM Department.  

Authorized services may require a co-pay.  Co-pays are specific to the patient’s health plan benefits and the services rendered at the time the patient is seen.  It is the responsibility of the provider of service to verify and collect the co-pay from the member at the time of service as the co-pay may differ from that stated on the authorization.

Potential quality issues and deviant medical practice identified by UM staff are reported to the Quality Management Department for review and action as necessary.  Results of the QM review and any trends identified are reported to the Peer Review Committee and sent to the QM committee on an annual basis.