CASE MANAGEMENT

Utilization Management and Case Management

The purpose of Utilization Management (UM) is to ensure appropriate authorization and usage of medical resources, monitor outcomes and provide information to managing physicians. AMM's utilization management staff assists in determining that services provided are medically appropriate, timely and within the scope of patients’ benefit plans. AMM advises the IPA UM Committee so that its actions, policies and procedures are in compliance with established Health Plan, government and NCQA guidelines.

AMM recognizes the importance of cooperative relationships among IPA physicians, other participating providers and UM staff. Physicians must understand the UM program and must actively participate in the process. AMM provides trained and experienced Case Managers to perform the daily review tasks and interface with physicians and hospital personnel involved. In concert with IPA physicians, and Administration, Case Managers develop and maintain a Utilization Management Program that includes the following:

  • Authorization Policies and Procedures

  • Emergency Room Authorization Criteria

  • Pre-admission Screening Program

  • In-patient Case Management

    • Admission review

    • Concurrent review/continued stay review

    • Out of plan/out of network review

    • Discharge planning

    • Skilled nursing facility review

  • Criteria for Surgical Procedures

  • Treatment Guidelines

  • Referral Guidelines and Procedures

  • Length of Stay Guidelines

  • Role of the Primary Care Provider and Attending Physician

  • Referrals to Physician Advisor

  • Physician Orientation, Continued Education

  • Transfer Guidelines and Procedures

  • Supervision of case management personnel

  • Review of UM Committee responsibilities, authority, membership, meeting schedules and staffing.

  • Compliance with Health Plan standards, audits and reviews.

  • Reporting of statistical information: authorization logs, transplant logs, denial logs, etc.

AMM will also establish and maintain a functional and efficient referral authorization request system that will be responsive to members and physicians. This system utilizes internet or facsimile technology and functions directly between AMM's Long Beach location and the IPA’s primary care and specialty physician offices. With the cooperation of IPA physicians, AMM can process all referral authorization requests and comply with industry standards for timely UM decisions. As such, most AMM clients qualify for the incentive monies offered by many Health Plans for authorization turn around timeliness.