Utilization Management Services

As healthcare costs continue to rise and PPACA requirements put pressure on medical loss ratios (MLR), it becomes ever more imperative health plans reduce and control administrative costs to remain competitive. Utilization remains a key factor contributing to these rising costs. MediCall's Utilization Management (UM) program will assist clients in mitigating rising medical expenditures due to overutilization while ensuring appropriate quality care is delivered promptly. Our utilization management services are fully compliant with both URAC and applicable state laws. MediCall currently provides, in substantial volume, UM services to some of the leading national and regional health plans throughout the country.

 

Our goal is to ensure the medical necessity of treatment, at the appropriate time and in the appropriate setting, through the application of nationally recognized evidence-based guidelines in order to control unnecessary medical costs.

 

MediCall's model and best practices ensure timely and consistent decisions delivered on behalf of our clients. Our UM team has the ability to work in our clients current utilization management software application to provide support for specific states, for vacation/absence coverage, for business continuity purposes, or to cover overflow during times of increased referral volume. Our quality assurance program ensures the highest degree of compliance with regulatory processes and consistent sound clinical determinations based on medical necessity.



UM Support

MediCall can also provide utilization management support services performed by our nurses using your software. By utilizing this service to off-load administrative tasks, your UM team will be more efficient and productive. Such administrative tasks include:

  • Requests for medical reports
  • Preliminary review and setup of the UM case
  • Documentation of medical findings
  • Preliminary application of guidelines
  • Notification of UM determination



MediCall Utilization Management Consumer Rights and Responsibilities


Consumer Rights

  1. To be treated with dignity and respect.
  2. To receive complete information about the diagnosis, proposed course of treatment or procedure, alternate courses of treatment or non-treatment, the clinical risks involved in each, and prospects for recovery in terms that are understandable to the consumer, in order to give informed consent or to refuse that course of treatment.
  3. To every consideration of privacy and to expect that all communications and records related to his/her care will be treated as confidential.
  4. To be given access to the utilization management department for timely responses to questions and requests made for service.
  5. To be given information on how to file a complaint.
  6. To be informed of MediCall utilization management policies including how to file an appeal when requested.
  7. To be informed of utilization management criteria used to authorize, modify or deny health care services when requested.

Consumer Responsibilities

  1. To be familiar with the benefits and exclusions of the consumer's health plan coverage.
  2. To provide the consumer's health care provider with complete and accurate information regarding past illnesses, hospitalizations, medications, and other matters related to health status.
  3. To treat the utilization management staff with respect and dignity.
.