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Utilization Review

Utilization Review. The money is there !. That means with UM coming aboard +200% Increase $$$$$$$$$$$$$$$$$$$$$$$$$$$. What do we accomplish? Utilization Management. We have been around since 1998. Wendy Danicourt was the first UR Specialist hired full-time in 1999.

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Utilization Review

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  1. Utilization Review

  2. The money is there !

  3. That means with UM coming aboard +200% Increase $$$$$$$$$$$$$$$$$$$$$$$$$$$

  4. What do we accomplish?Utilization Management • We have been around since 1998. Wendy Danicourt was the first UR Specialist hired full-time in 1999. • We obtain certification for services from the Insurance /Managed Care Organizations • We do pre-certifications, continued stay reviews, appeals, etc. • We are on the phone, fax, internet, writing letters justifying why a client needs to be in PAR for treatment. • We collect the data to see what the consumer needs. The needs of our population changes and we keep the pulse to match what agency provides and needs of the community.

  5. How we do what we do • Collect insurance information at first contact • Call for benefits • Inform the client of benefits before they show • Sign about fees if not covered • Work with the client on copay and deductibles • Work close with programs doing UM meetings weekly • Facilitate the transfer to other PAR programs • Working with programs so services are billable

  6. TEAM work • Work very close with Clinical and Financial • Clinical – justifying the LOC • Financial – providing information to client or guarantor to keep updated on status • After the services – move it through the system to get the $

  7. Goals • We have input on the goals. Each program and overall Agency

  8. GOALS • Not only goals for $ • But if using DCF / State $/ Grants Goals of Utilization goal for each month. • Expect denials – goal on Appeals • Impact of grants/projects/clinical trials

  9. UM- Data • UM can be looked at for the driver of new business – IF data is collected. (move from the gut feeling to data and clients are showing us a needs for…) • We have moved from tracking in Microsoft Word documents to CTS – and CMHC - allows reports to be run automatically and for various measures. • More staff to have access not only for the financial information but the clinical information entered by the UR Specialist.

  10. Questions??????

  11. Where do we go from here?

  12. Utilization Management • Increase Revenue • Increase number of Managed Care Organization contracts • Increase services payable by Managed Care Organization • Increase variable length of stay at programs – allowing them to be Managed Care friendly • Improve relations with Managed Care Organizations • Improve coordination of care of clients covered by insurance – step downs and step ups – Detox to Intensive Outpatient Program to Outpatient Program or Outpatient Program to Detox Inpatient Program. Be viewed as a leader in the community for the Managed Care Organizations to contact • Healthcare Reform! • Primary Care coordination. • UM across the board.

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