Reducing Healthcare Risk & Improving Payment Integrity with Utilization Management

April 6, 2022
2 Minute Read

It’s estimated that nearly $154 billion in improper payments were made in FY21, resulting in downstream effects on patients, providers and payers. Effective Utilization Management (UM) can help mitigate the risk of improper payments, including costly audits, shifting from post- to pre-payment reviews to ensure a robust payment integrity program and reduce administrative burden.

National healthcare expenditures grew by 9.7% to $4.1 trillion in 2020, far exceeding Centers for Medicare & Medicaid Services’ projected growth rate of 5.4% annually from 2019-2028. The National Health Care Anti-Fraud Association estimates that anywhere between 3%-10% of these expenditures are fraudulent, driving higher premiums and out-of-pocket expenses for consumers, increased costs of providing insurance to employees for private and governmental employers, losses for providers and payers resulting from audits, and an overall reduction in benefits or coverage.

In an recent webinar, “Claims and Utilization Management (UM) Risks,” Todd Gower, VP of RGP Healthcare, and Kenneth Stockman, CEO of Beacon Healthcare Solutions, will explore how organizations can employ utilization management processes and technologies to proactively identify and mitigate risks, remain compliant with CMS requirements, and strengthen their payment integrity.

Getting Proactive About Payment Integrity

One of the barriers to payment integrity is payers’ historical reliance on post-payment reviews to ensure appropriate reimbursement was sent to providers for medically necessary services and that claims were submitted according to agreed-upon billing rules. Unfortunately, while often seen as convenient, this “pay and chase” strategy not only results in losses, but also contributes to abrasion between payers and providers, according to a recent report by Frost & Sullivan.

Healthcare Utilization Numbers

The message is clear: Payers must shift to a proactive, provider-friendly strategy that includes techniques like pre-submission notifications to identify errors before claims are submitted, improving accuracy and reducing the potential for a post-payment audit.

Implementing Utilization Management Best Practices

Utilization management can help payers evaluate the efficiency, appropriateness and medical necessity of the patient care and services, using a variety of metrics. While UM does include retrospective reviews, prospective and concurrent reviews can also be performed to eliminate unneeded services and support point-or-care decisions—getting ahead of costs and reducing friction.

In our webinar, we’ll dig into each of these types of reviews, sample metrics and best practices as well as how to align your organization for UM success.

Join us to learn:

  • How to remain compliant with proactive monitoring
  • Why payer-provider communication is essential
  • How payers can collaborate cross-functionally to mitigate risk

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