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UTILIZATION MANAGEMENT

HealthSmart's Utilization Management program is designed for employers and providers to ensure optimal, cost effective outcomes while maintaining a focus on quality care for both inpatient and outpatient services. Nationally accepted criteria is utilized in determining medical appropriateness. Continuous monitoring and communication with health care providers allows us to follow the patient throughout the healthcare delivery system and assure that appropriate settings and resources are utilized. Reports are generated on a regular basis to provide meaningful interpretation of data regarding analysis of utilization, savings, and the impact of benefit design.

Utilization Review: Inpatient

Inpatient Care nurses work with patients and providers for the patients' best interests by helping to ensure appropriate care and maximizing clients' medical benefits. Nurses evaluate and determine medical necessity and the appropriate setting for each level of care. Issues explored include whether a continued stay is necessary to achieve the desired result and whether there are cost-effective alternatives available without sacrificing care. Our goal is to increase the quality of care our patients receive by making sure they obtain the right care at the right time in the right setting.

Utilization Review: Outpatient

Outpatient Care nurses focus on high-cost, high-utilization outpatient procedures. As medical technology for outpatient treatment has evolved and become more sophisticated, the volume of outpatient procedures and associated costs have risen. Employers have seen outpatient costs parallel those of inpatient costs. Outpatient care management helps our clients control these expenses.

URAC Accredited for Utilization Management

On April 1, 2009, URAC awarded HealthSmart Care Management Solutions the Certificate of Full Accreditation for its Health Utilization Management services. URAC’s mission is to promote continuous improvement in the quality and efficiency of health care management through processes of accreditation and education. The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards. “By applying for and receiving URAC accreditation, HealthSmart Care Management Solutions, L.P. has demonstrated a commitment to quality health care,” said Alan P. Spielman, URAC president and CEO. “Quality health care is crucial to our nation’s welfare and it is important to have organizations that are willing to measure themselves against national standards and undergo rigorous evaluation by an independent accrediting body.” For more on URAC, click here.

Quality Service

Our team of experienced Registered Nurses and physicians are available 24 hours a day to ensure the needs of patients, health plans, and providers are addressed quickly and efficiently. Our comprehensive, straightforward Utilization Management solutions include the following programs:

  • Precertification
  • Predetermination
  • Emergent Admission Review
  • Concurrent Review
  • Retrospective Review
  • Discharge Planning
  • Independent Review Panels
  • Case Management Identification
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