Medical Case Management Services
Medical Case Management is defined as the timely coordination of medical care to meet an individual’s healthcare needs and maximize the use of benefit dollars while supporting a quality medical treatment plan. It involves review of the whole picture of the participant’s health and medical status, problems, treatment necessary, treatment being given and alternatives to care. It also includes a review of the cost of services, drugs, equipment, supplies; price negotiation; and long-term cost estimates.
Utilization Management Services
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.