April 20, 2024

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The Best Heatlh Under One Roof

Medical Case Management Best Practices

It’s no secret that today that health plans and managed care organizations are putting tremendous amounts of money into proactively managing the small percentage of their subscriber populations who consume the majority of their health care resources. Case management utilization review, medical management and disease management are some of the generic terms that are used to describe this process. Independent review organizations act as a key support element in the health care decision making process. They help case managers, utilization review and utilization management nurses improve the health care delivery process so that critical care populations are getting properly attended to with the right treatments, each time, every time. Only independent review organizations can provide for this critical decision support to the managed care organization. Managed care organizations, utilization review and utilization management departments attempt to perform these functions internally without using the appropriate specialists with the latest training in active practice run the risk of not being able to distinguish between necessary and unnecessary treatments. Such decision making is the role of an IRO.

Case managers outsource their medical claims decision making to independent review organizations for a simple reason: They don’t have the medical expertise and specialist knowledge in all areas of care management to make effective medical decisions concerning care recommendation for some patients. By involving an independent review organization in their decision making, case managers are able to allocate health care resources quickly and cost effectively to the right people with a high degree of confidence that those resources and those treatments were assigned effectively based upon the standard of care, medical necessity and what’s in the plan language. Case managers who use independent review organizations are able to improve their service to their clients and to their patients, assuring effective health care delivery. At the same time, IRO help streamline the decision making process and allow for treatments to happen earlier…sometimes with the added benefit of saving lives or improving patient outcomes. Case managers and utilization review managers who actively use IROs for this purpose often comment on how fast and easy it is to get quick determinations that improve medical outcomes for their active cases.

We’ve seen many examples of case managers using an IRO to speed up treatments and improve patient safety and reduce the cost over the patient care life cycle. Case managers and utilization review nurses who deploy IROs also find that it’s a much faster and easier way to make healthcare decisions compared to waiting on internal or allied doctors. Since independent review organizations are in the business of supporting fast and quality patient health care decisions, they’re able to make decisions faster, easier and at a lower cost compared to other processes. This is why case management, utilization review and other types of medical management firms are increasingly turning to IROs as a key resource in their healthcare decision making toolkit.