Utilization Management

Medications, surgeries, personalized therapies, and healthcare treatments can all lead to huge bills for payers and patients. Many of these expensive procedures can be avoided or replaced by simpler, cost-effective alternatives that take place in outpatient settings. To verify cost of care and medical necessity of procedures and treatments, payers must conduct authorization reviews of the care requests that providers raise.

Prior authorization for care requests typically requires a significant amount of administrative work by both payers and providers. The review process can be tiresome and time-consuming, with multiple screen switches and data from various sources. There are cases where authorization requests are submitted to payers for services that don’t require prior authorization, resulting in delay of care for patients.

To simplify this process and make sure services are aligned to medical necessity guidelines and care is provided at the right time in the right setting, Utilization Management provides these capabilities for payer and provider organizations:

• Get Started with Utilization Management
  To get started with Utilization Management setup, complete prerequisites such as enabling person accounts, installing Omnistudio, ensuring you have the correct permission sets and permission set licenses, and setting up the relevant data in your org.
• Authorization Request Process Setup for Payers
  Help users in your payer organization to easily handle and review authorization requests with a predefined app and a set of Omniscripts. These components present a centralized view of the information required for prior authorization and concurrent reviews, from eligibility check, to uploading supporting documents, to final approval.
• Authorization Request Process Setup for Providers
  Help your provider users to easily create and submit authorization requests using FHIR-aligned, industry-specific APIs, along with a predefined suite of Integration procedures and Omnistudio Data Mappers. These components retrieve member information, service requests, and other details required to create an authorization request record and submit the request to the payer.
• CRM Analytics for Utilization Management
  Set up and configure CRM Analytics-based dashboards contextualized for user personas to streamline Care Request management and optimize the prior authorization request workflows. You can also use the Approval Rate insight cards to support quicker clinical reviews and decisions by providing relevant insights during the review process.
• Artificial Intelligence for Utilization Management
  Get predictions about the likelihood of prior authorization requests breaching service-level agreements (SLA), and recommendations about services that are likely to be received and requested by payers and providers.
• Coverage Requirement Discovery for Payers
  Support your users with automated workflows for managing coverage requirement discovery requests. Utilization Management processes incoming requests for coverage requirement discovery and returns responses using FHIR-aligned Clinical Decision Support (CDS) hooks such as the appointment-book, order-select, order-sign, order-dispatch, encounter-start, and encounter-discharge hooks.
• Documentation Templates and Rules for Payers
  Da Vinci Documentation Templates and Rules (DTR) is a framework under the HL7 FHIR standards that facilitates the exchange of documentation requirements between payers and providers. Utilization Management supports DTR for payers so that you can communicate your documentation requirements to providers in real time, directly to their EHR systems or SMART on FHIR apps. DTR enables the use of standardized templates and rules in the exchange of critical healthcare documentation, ensuring compliance and reducing administrative burden.
• FHIR Subscription for Utilization Management
  Use the FHIR subscription framework to send subscribers timely notifications of event changes. Publish the topics or events that are available for subscription so that clients can subscribe by providing their endpoints.
• Handle Care Requests with Utilization Management
  Utilization Management (UM) is a health plan's way of working with plan members and medical providers to influence decisions via case-by-case review of the appropriateness of care.