Utilization Review Services
Utilization Review Services provide quality and cost controls for employers and their employees.
All network providers have completed a rigorous credentialing process and have been evaluated by their peers according to high medical standards of skills and expertise.
Utilization activity is reported to all employers on a quarterly basis. Reporting is customized to suit the needs and objectives of the employer and includes the following data:
- Total number of inpatient hospital admissions
- Number of admissions by type of service, i.e., medical, surgical, etc.
- Average length of hospital stay
- Days and admissions per 1,000
- Comparison of admission data to Milliman Care Guidelines and variance reporting
- Days denied and avoided by month and year-to-date
- Estimated cost savings year-to-date
- Quarterly comparative color graphs
Community Health Alliance has developed an aggressive approach to help lower health care costs. Costs are carefully controlled by:
- Utilization review
- Precertification of inpatient admissions
- Precertification of outpatient services
- File review:
Prospective
Concurrent
Retrospective - Case management identification
- Case management services
- Preventive services
The most effective way of controlling health care costs is through utilization review, a process in which the utilization of health care services is monitored for appropriateness, medical necessity and cost effectiveness.
CHA provides use of local nurse reviewers who work with the network physicians to use the most appropriate setting for care.
Precertification with prospective review is a key component of the utilization review process. Hospital stays need to be approved in advance to confirm medical necessity and to assign an appropriate length of stay. If a hospital stay is not precertified, benefit reductions may be applied.
The utilization review nurse works with physicians to determine if the proposed treatment can best be performed in an outpatient setting.
Milliman Care Guidelines have been adopted by the Community Health Alliance as criteria for precertifying inpatient hospitalizations, determining appropriate length of stay and variance analysis. Outpatient procedures and tests can also be precertified.
Utilization review duties are performed by registered nurses. The registered nurses are assisted by a utilization review representative.
The medical director is available to the utilization review staff for consultation on medical necessity questions. A panel of specialists serves as consultants for specialty questions.
Employer Advantages
- Quality health care provided through CHA's network of credentialed physicians
- Flexible design of quarterly reports
- Cost savings through prospective review of all scheduled inpatient and outpatient procedures to confirm most appropriate facility usage
- Precertification done locally for maximum health care controls
Employee Advantages
- Wide choice of health care providers
- High quality health care
- Utilization of network providers to lower out-of-pocket expenses
Community Health Alliance is locally owned and operated offering quality satisfaction and outcomes while utilizing local providers.