Medical Cost & 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.