Utilization Management

Cost Containment Services

Utilization Management

Utilization Management

The purpose of utilization review is to target and medically manage the benefit plan’s most costly services by determining medical necessity, reviewing the proposed plan of treatment for medical appropriateness, determining whether the requested medical services should be provided and exploring if alternative options have been considered that may be less costly and/or more effective. Effective utilization review results in improved benefit utilization, immediate cost containment and improved care and early identification of potential high-dollar and high-risk procedures and services for referral to medical case management.

Early identification and management of the health care issues of your insured members greatly impacts the positive financial performance of your medical, disability and prevention management program. Medical Rehabilitation Consultants provides personalized services in the following manner:

Pre-certification/Pre-authorization Review:

This review provides early identification of potential high-dollar and high-risk procedures and services. We target and medically manage the plan’s most costly services to determine medical necessity and review the proposed plan of treatment for medical appropriateness, determine whether the services should be provided and if alternative options have been considered that may be less costly and/or more effective.

Your insured members, their representatives or the provider contacts MRC’s professional medical staff. Each call is personally answered by our office staff and relayed immediately to the appropriate registered nurse. During holidays, weekends, and non-working hours, all calls are answered by our voice messaging system. A phone number is given in the event of an emergency during these times.

Information regarding the nature of the services and the underlying medical problems are gathered by the medical professionals in the office. After all of the information is obtained, a determination is made regarding the medical necessity, appropriateness and relatedness of the service, length of stay, number of treatments, etc., prior to certification and according to your established guidelines. The turnaround time for pre-certification requests is less than twenty-four (24) hours. When appropriate, negotiation of costs for products and/or services are initiated and all cost savings reported.

Medical Rehabilitation Consultants’ utilization review staff initiates follow-up telephone calls for every potentially high-risk and high-dollar certification. The calls are made to assess the outcome of the services, determine if more services are needed, and to provide education and support to the clients regarding their plan of care. This strategic approach to pre-certification allows your members to access health care resources in a very proactive rather than punitive fashion and encourages cost-effective use of services. Our process has been instrumental in providing substantial cost savings to the benefit plan and participant by preventing unnecessary hospitalizations, re-hospitalizations, services, and procedures.

Services that we recommend to be pre-certified to maximize cost containment and impact include:

Inpatient hospitalizations

All inpatient and outpatient surgical procedures
Diagnostics: To include heart catheterizations, CT scans, MRIs, MRAs, IVPs (radiographic examination of the kidneys, ureters, and bladder), etc.
Home health care services
Nursing and rehabilitation facility services
Physical, occupational, and speech therapies
Purchase of Durable Medical Equipment costing $1,000 or more
Rental of Durable Medical Equipment with purchase value of $3,000 or more
Hospice care
Orthotics and prosthetics over $500.00
Hyperbaric Oxygen Treatments

Concurrent Review:

Utilization review of ongoing-services currently in progress is conducted for your members for both scheduled and unplanned admissions and procedures. Reviews are conducted within twenty-four (24) hours of the notice or by the next business day if the admission falls outside ordinary working hours. Information regarding concurrent reviews is included in the regular reporting cycle.

Retrospective Review:

Utilization review is conducted after services have been provided to the patient that were not pre-certified or concurrently reviewed. The medical records are reviewed for medical appropriateness and relatedness of services. Information regarding the outcome of the review is included in the regular reporting cycle.

Second Medical Opinion:

The utilization review staff recommends second medical opinions for medical services specified by the plan to obtain an opinion about the medical necessity and appropriateness of specified proposed services. Second medical opinions are also recommended when the clinical evidence or the medical community does not offer support for the medical resources for the service being requested. Information regarding the rationale and the outcome of the second medical opinion is included in the regular reporting cycle unless it is related to pre-certification, in which case it will be provided immediately.

Conditions that initiate immediate medical case management:

The following are some example catastrophic injury, illness and disease conditions that initiate immediate medical case management:

  • High-risk pregnancy
  • Premature birth
  • Major or multiple congenital anomalies
  • Transplants
  • Dialysis
  • Circulatory/Cardiovascular disease or failure
  • Thermal burns or frostbite (child > 10%, adult > 20%)
  • Crush Injuries, amputations
  • Multiple trauma
  • Respiratory dependency
  • Emphysema
  • Chronic bronchitis or asthma
  • Spine injuries
  • Brain injuries or trauma
  • Unconsciousness – any cause
  • Electrical injuries
  • Tumors
  • Cancer
  • Radiation treatment
  • Chemotherapy
  • AIDS (Acquired Immune Deficiency Syndrome)
The following situations are “red flags” due to their known risks as high-dollar claims based on diagnoses and slow or lack of progress toward recovery and resolution.

All designated claims are reviewed on a case-by-case basis as candidates for medical case management:

  • Long-term care needs
  • Extended in-patient course
  • Equipment/supplies/therapy needs
  • In-home service needs
  • Poor recovery/complications
  • Complicated diagnosis and/or treatment plan
  • Delayed diagnosis/no diagnosis
  • Changing diagnosis
  • Multiple diagnoses/diagnostics
  • Multiple medical providers
  • Patient dissatisfaction/lack of information
  • Bariatric surgery
  • Failed treatment
Emphasis is placed on appropriate medical care, progression of treatment, return to work, education and claim resolution resulting in cost containment.

Our unique program provides:

    • Comprehensive initial assessment
    • Physician consultation
    • Patient and family assessment
    • Patient and family education
    • Home needs assessment
    • Review of various treatment options
    • Review of work-related issues
    • Cost containment services
    • Follow-up recommendations
    • Monthly reporting to your specifications

The benefits of medical case management include:

    • Early Intervention
    • Efficient utilization of benefits
    • Cost containment
    • Appropriate, effective and timely treatment
    • Negotiated rates
    • Patient encouraged to actively participate in their health care
    • Improved medical compliance
    • Coordination of care
    • Educational resources

A MediOpin Company . . . Medical Rehabilitation Consultants, LLC. © 2021. All rights reserved.