Purpose and Scope
The Utilization Management (UM) Program is designed to monitor, evaluate, and manage the quality and cost of healthcare services delivered to all members of the IPA. The utilization management structures and process are clearly defined and responsibility is assigned to the appropriate individuals.
The program will ensure that:
- Services are medically necessary and are delivered at appropriate levels of care.
- Medical services are provided by the IPA contracted providers and practitioners unless authorized by the EXCEL MSO, LLC (EXCEL) Chief Medical Officer, the IPA UM Committee, or the IPA Senior Medical Director.
- Services are not over utilized or under utilized.
- High quality medical care is offered in a timely manner with consideration to the urgency and emergency of the situation.
- Services are authorized timely and efficiently with consideration to the urgency of the situation.
- Guidelines, standards, and criteria set by health plans, governmental and other regulatory agencies are adhered to, as appropriate.
- IPA will maintain regulatory compliance with respect to various health plans in general and also specific contracted member populations, (e.g. Commercial, Medicare, and Medi-Cal.)
- IPA utilizes standard criteria and informational resources to determine the appropriateness of healthcare services.
- The utilization management team of physicians, clinical staff, and nonclinical staff carry out the responsibilities designated for their level of expertise.
- Compensation plans for the IPA physicians do not include incentives, direct or indirect, for making inappropriate review decisions.
- The Utilization Management Program will be reviewed and approved at least on an annual basis by the Utilization Management Committee and Board of Directors. Supporting policies and procedures will be reviewed and approved at least annually by the UM Committee.
- The Utilization Management Program will be integrated with the Quality Management Program to ensure continuous quality improvement.