Focused Utilization Management

 

Determines criteria-based medical necessity for targeted high-cost, complex diagnoses and procedures.

The Focused Utilization Review program concentrates RN review on high dollar, complex diagnoses and procedures.  Physician Review is available as needed.  Focused Review also includes precertification for all Inpatient admissions, and allows for early identification and referral to Case Management. 

 

Fast Facts

• American Health’s Focused Utilization Management program is accredited by URAC.
• The service is guided by American Health’s Total Quality Management Program, which sets the highest priority on timeliness, accuracy, quality of care and cost-effectiveness.
• American Health holds licensure in all required states.
• Case Management trigger list automatically flags cases that may benefit from Case Management intervention.
• Length of Stay is established using national Patient Assigned Stay (PAS) Tables at the 25th percentile.
• Focused reviews are conducted by registered nurse reviewers, and are based on established national medical criteria.
• The reviewers interact with attending physicians to obtain agreement on treatment plans and appropriate lengths of stay. 
• Focused inpatient cases are continually monitored throughout the hospital stay to assure quality and appropriateness of care.
• All nurse reviewers have at least 5-8 years of clinical experience.  They view the best patient outcomes as their goal.
• The review also benefits from American Health’s own state-of-the-art computer system.  The system was designed to facilitate all of the steps in the focused review process – from initial patient or provider contact, through evaluation and recommendation, culminating with treatment and discharge planning.

Medical Director and Panel of Specialists

Overseeing the Utilization Management program is a Medical Director certified by the American Board of Quality Assurance and Utilization Review Physicians.  The program also offers the expertise of American Health’s own panel of board-certified, practicing physician specialists, in addition to external panels of more than 600 specialists.