Utilization Management & Decision Making

United Physicians, in collaboration with Clinical Resource Management Staff and our physicians, strive to provide our patients and members with the highest quality of care in the most appropriate setting.  Medical management decisions are based on medical appropriateness and benefit coverage.  When applying criteria to chart review as described in the policy "Admission and Continued Stay Review," the following factors need to be considered as well as other nursing assessment and review findings:

  • Age
  • Co-morbidities
  • Complications
  • Progress of treatment
  • Home environment
  • Local delivery system
  • Coverage for such care or ability of provider to meet recommended care
  • Psychosocial situation

Additional consideration is to be made regarding the decision if the care is available and can be effectively provided in an alternative setting such as home care, skilled nursing facility, sub-acute, hospice, or home with healthcare education.  Consideration is also given for community support and access to needed services.  Please refer to the "Continuing Care Options by Patient Characteristics," dated 4/18/00 and reviewed October, 2008.

There are no incentives, including financial, for utilization management decision-makers based on denials of payment or coverage.  The physician under review is permitted access to the Physician Reviewer and the criteria that went into the decision.  The Physicians Reviewer is allowed to share the criteria set which is referred to for decision making.  Additionally, the patient and physician should be given information and assistance regarding alternative options of care that will give access for needed services for alternative care.

Another means of measuring cost-effective care is to monitor a physician's practice pattern for not only over utilization but also under utilization.  This is done by claims review on all areas, including comparisons to the physician's peers through United Physicians' Performance Status Review and other educational processes.  If you have any questions regarding a UM decision, please feel free to contact Harry Doerr, M.D. or Michael Williams, M.D.

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