Health insurance organizations try to control the cost of medical care through preferred providers, referrals and central management. The technique of utilization management is another way to manage the cost of medical services and health care. The way that the cost control method works is by examining each patient's medical needs on a case-by-case basis. Medical providers provide professional, medical suggestions to patients based on whether the care and services they are requesting is appropriate. In some cases, a patient requests a procedure or referral to a specialist that is not in his or her best interests.
Part of the utilization management method involves a utilization review. The review process involves trained medical professionals who are directly involved in the patient's treatment, peers of the doctors and nurses, a program manager, and healthcare utilization an adviser to the doctors. This ensures that the patient is not being mislead by the primary care physician or specialist directly involved in treating the patient's ailment. Since each utilization company could have different policies and procedures, the review process could involve various steps. Some companies conduct the review process on a more frequent basis than others. In other scenarios, the responsibilities of each person involved in the review process is different.
myNEXUS is an example of a company that employs utilization as a method of controlling medical costs. The primary aim of the company is to help managed health care plans save money on care. The secondary aim of the company is to improve the quality of medical care patients receive. Utilization is a successful way of managing costs since the technique relies on past and present patient data. This is crucial to improving health care quality since this data can include patient surveys and perceptions about the level of care they receive in various medical facilities. The idea of controlling costs through population health management data is not necessarily unique to utilization, but the technique does leverage it in a different manner.
Patients who do not need to be admitted to emergency rooms, for example, are referred to a more appropriate care setting. In a utilization network, emergency room staff are able to gain instant access to the patient's past medical history and analyze the patient's current medical complaint. Patient data is leveraged to both control the authorization process and reduce the amount of risk an individual medical facility is exposed to. Utilization has promising benefits for both medical providers and patients due to its ability to leverage data. Patients can receive a better level of care and medical providers can reduce unnecessary costs.