Utilization Management

Your HMO insurance plan mandates that every admission be authorized and the case followed during the hospital stay. This is also known as Pre-Certification and Concurrent Review. These programs are established to ensure that you receive the most appropriate and cost effective health care.

• Your Primary Care Physician must pre-certify all upcoming admissions with Managed Health Care Associates
• Your Primary Care Physician must notify Managed Health Care Associates of all emergency admissions.
• Concurrent review ensures that your length of stay is appropriate given your diagnosis and treatment plan.
• Your Primary Care Physician and/or Managed Health Care Associates may recommend other courses of treatment that could avoid hospital admission or alternate treatment settings resulting in fewer in-patient hospital days for you.

Managed Health Care Associates works very closely with your Primary Care Physician when reviewing in-patient hospital cases, however it is your responsibility to comply with the treatment recommendations made by your physician.

Communication With Utilization Management Staff

Please be advised that after hours calls regarding utilization management decisions for referrals, outpatient surgeries, and inpatient care are taken by a voice mail system. Instructions for leaving a message are given by the after hours greeting by calling our office at 773-271-0880. Messages that are left for staff regarding utilization management issues are returned within one business day of receipt. Collect calls will be accepted during normal business hours only in regard to utilization management decisions.

Utilization Management Affirmation

At Managed Health Care Associates, Ltd. we affirm that:

• Utilization management decision making is based only on appropriateness of care and service and existence of coverage.
• Managed Health Care Associates does not specifically reward practitioners or other individuals for issuing denials of coverage or service care.
• Incentive programs are not utilized to encourage decisions that result in under-utilization.
• There is no conflict of interest between Managed Health Care Associates and its utilization management decision makers.

 

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