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Utilization Management Case Study

1010 Words5 Pages

Controlling healthcare costs has been a primary focus of legislation and healthcare reform for nearly a decade. But, at what cost? Do the strategies intended to control healthcare spending negatively impact patient care? Are payers using the process of utilization review to their advantage to deny claims submissions?

Shutterstock image ID: 104400305 ---- alt tag: Medical Claim with a denied stamp because of utilization management --- Caption: Could providers be using utilization management to their advantage to deny essential medical claims?

Let's discuss the topic of utilization management (UM) and take a look at industry news, studies, and polls to see how many claims are being denied, and how UM affects this trend. We also discuss a solution …show more content…

Published by NCBI, the Institute of Medicine (US) Committee conducted a study in 1989 that examined the role of utilization management, titled: "Controlling Costs and Changing Patient Care? The Role of Utilization Management." The authors of the study examined the implementation of utilization management as a means to cut healthcare spending and control costs. They also evaluated the impact this had on how physicians were able to provide care to patients.

"With great rapidity and relatively little public awareness, a significant change has taken place in the way some decisions are made about a patient's medical care. Many decisions like those just described, once the exclusive province of the doctor and patient, now have to be examined in advance by an external reviewer, someone who is accountable to an employer, insurer, health maintenance organization (HMO), preferred provider organization (PPO), or other entity responsible for paying all or most of the cost of the care. Depending upon the circumstances, this outside party may be involved in discussions about whether a service is needed, how treatment will be provided, and where care will occur." - Controlling Costs and Changing Patient Care …show more content…

Many doctors are experiencing difficulty getting insurers to authorize several prescriptions.
Overly Restrictive Step Therapy Programs. Often insurers require the patients try a series of alternative treatments that are cheaper before agreeing to pay for the one prescribed by the doctor.
Overly Expansive Formulary Exclusions. The article provides the example of CVS, who has doubled its list of treatments excluded from its formulary in the past three years. Also noted is Express Script, whose list has grown by 77 percent within the same time frame.
Overly Aggressive Non-Medical Switching. Patients are often forced to switch to cheaper medications, even in the middle of a coverage year, because the formulary tiers have changed treatment coverage.
Overly Inclusive Adverse Tiering. Patients with certain conditions are often discouraged to enroll in health plans because all or most medications that are used to treat a particular illness have been placed on the formulary tier with the highest co-pays.
President and co-founder of Global Healthy Living Foundation, a founding member of DPRP, Seth Ginsberg, had this to

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