Utilization Management - Clinical Reviews

We are looking to identify the best fit for the utilization management process where a decision is made on the next steps for some type of planned or requested event.

The definition that best explains how we are going to use Utilization Management data is outlined here:
The Institute of Medicine (IOM) Committee on Utilization Management by Third Parties recognizes UM as “a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.”

We are looking to see if this should be mapped to a procedure request or to some other request type. The essential use cases we will drive are based on state:

Prospective review is conducted at the onset of a service or treatment and is also referred to as precertification or prior authorization. This review is performed before care is rendered in order to eliminate or reduce unnecessary services. Prospective review may have the impact of not authorizing or limiting care that had been recommended by the evaluating provider(s).

Concurrent reviews performed during the course of treatment or episode of care. Intervention occurs at varied intervals and may encompass case management activities such as care coordination, discharge planning, and care transitioning. Concurrent review may have the impact of curtailing an existing episode of care.

Retrospective review is conducted after the service has been completed and assesses the appropriateness of the procedure, setting, and timing in accordance with specified criteria. Such reviews often relate to payment and may result in denial of a claim. Financial risk for a retrospective denial is often borne by the provider.

There’s a variety of ways to approach these use-cases. Prospective review can be managed through pre-authorization requests using the Claim resource. This typically involves proactive behavior by the clinician (because they’re aware that the service desired requires a pre-auth). You can also use CDS Hooks to trigger intervention within a practitioner’s EHR system that can check as a service is being ordered. The hook can trigger the collection of additional information needed for a pre-determination and/or allow the adjudication system to retrieve the relevant information itself. It can also propose alternatives (typically those that are covered, are lower cost or are considered first-line treatments that must be attempted prior to the proposed treatment).

For concurrent review, the bulk data access process can retrieve current and historical records for all covered patients and can be used to retrieve “what’s changed” information to allow a payor to have a current picture of all patients under care. This might be used to intervene in particular cases, but it can also be used to build knowledge about the cost effectiveness of particular treatments.

For retrospective review, the Claim and ClaimResponse resources allow for claim submission and conveying adjudication results (which might be acceptance, rejection or modification of the requested reimbursement).

The Claim and ClaimResponse process, whether prospective or retrospective can be managed using different workflow approaches including messaging, REST and services, depending on the infrastructure and desired behavior of the parties involved. Take a look at the workflow page for information about the possible options.

HL7 has a payor user group that you might want to engage with and there’s also a Financial Management workgroup that’s responsible for a number of related resources.

Hope that helps.

Thanks Lloyd, very helpful! We’ll investigate the claims resources for our use cases. Is it typical to try to reconcile the pre-auth to the claim? We get claims data and auth data w/out any common key. We had discussed using an encounter but w/out common keys. We would have to try to use some type of fuzzy logic to match the pre-auth and claim to a common encounter(s).

The Claim resource is actually used for pre-authorizations, pre-determinations and claims. The claim has the ability to point to a pre-auth.