Stop Throwing Bodies at Utilization Management
Prior-Authorization is performed on only 5% - 12% of claims volume (Medical Economics, 2013) yet represents significant potential for cost savings. Pre-certification takes it further by utilizing care plans to maximize health outcomes while minimizing the risk of readmission. Today the process is manual and requires highly skilled, clinical personnel. Due to this the cycle time is 2-30 days for a response (AMA, 2012). It is time consuming, costly and prone to error. Context has changed the game through automating this process.
Imagine your utilization management guidelines and care plans are automated through a complex rules engine. As prior-authorization or pre-certification requests come in electronically, they would be analyzed real-time. Instantaneous feedback would be delivered describing:
- Success or failure against specific utilization management pre-requisites (including history)
- Adherence to your recommended care plan (completeness, accuracy)
- Unnecessary procedures that don’t match the diagnosis
- Identification of potentially thousands of coding and utilization issues
- Reference based pricing (Medicare / UCR) to guide you in negotiating provider fees
This will enable your clinicians to focus time on exceptions, minimize their research and spend more time on care planning.