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Monday, March 23, 2015
  Clinical Accuracy Spoken Here  

Population Health: Is This
Really Necessary?

With Managed Care Organizations (MCOs), the emphasis is on facilitation and education of members and providers through utilization management (UM), providing members with access to quality care and monitoring the appropriate utilization of services.

Four key elements when making authorization determinations are:

  • Is the patient an eligible member of the MCO, and if so is the MCO the primary payer?
  • Does the member’s benefit allow the requested treatment?
  • Are there network limitations that must be met?
  • Does the clinical documentation provided meet medical necessity for the procedure or level of care?

[Reference: Population Health, Module A, Prior Authorization]

  Excellence in Case Mgmt  

Population Health: Let’s Review

As the MCO case management focus moves from prior authorization to concurrent review considerations, the MCO CM role mimics that of the HCM in many respects.

When early conversations confirm benefit requirements, when medical necessity criteria are met throughout the stay, and when duplication of service and never events are controlled, denial rates are not an issue and appeals are unnecessary.

The CM focus can shift to effective discharge planning, including consideration of transition of care needs for each patient.

[Reference: Population Health, Module B, Concurrent Review]

  Improving Patient Care...  

Population Health: Risky Business

MCO CMs, through early collaboration and communication with HCMs, can assist in identification of:

  • Patient risk status related to previous care
  • Resources that have proven to be effective previously
  • Patients who may be unexpectedly at risk
Transfers between hospitals and post-acute providers would be expected to improve with a standardized assessment protocol that promotes better communication across settings of care. Various agencies have developed risk assessments and plans for managing readmissions.

[Reference: Population Health, Module C, Transitions of Care]


Tom RasmussenTom Rasmussen
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