How We Help // Care Management

Utilization Management

Managing quality care for optimal, cost-effective outcomes

UM.jpgHealthcare is a delicate balance between improving outcomes while lowering costs. HealthSmart's Utilization Management helps our clients an effective and efficient medical care delivery system. Our team evaluates the medical necessity and length of medical services provided by participating physicians, hospitals and other ancillary providers.

We work to identify potential overutilization and underutilization, either of which can impact outcomes and costs. Our registered nurses use evidence-based national clinical guidelines to ensure members receive appropriate care for their condition in the most appropriate setting.

Utilization Management is also a member advocacy tool. With our bundled-pricing solution, MyDecision™, members pay no out-of-pocket costs for many elective surgeries and get expert guidance from Referral Specialists.

  • Lowers cost by identifying services/procedures that are not medically necessary, cosmetic, experimental or investigational
  • Precertification is designed to procedures triggers referrals into Case Management and Disease Management in real time to curtail overall costs
  • Ensures members receive the right care at the right place

We all know improving member health and keeping members healthy is the key to lowering costs. With our integrated approach and commitment to achieving high employee engagement, we help clients stay ahead of the ever-rising costs of healthcare.