Utilization Management – Friend or Foe to Accessing Necessary Treatment

Posted in Administrative, Blog at Aug 11, 2017


 

Matthew Mesibov, PT, GCS
Clinical Physical Therapy Specialist

 

Have you ever been told that you can no longer have therapy services because the insurance company is denying payment for services? If so, what may be at work is “Utilization Management”.

Utilization management (UM) was defined in 1989 by the Institute of Medicine (now the National Academy of Medicine) 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 decisions through case-by-case assessments of the appropriateness of care prior to its provision.”[1]

Though perhaps well intentioned, over the years as UM has increased, treating cost of care as an outcome metric may lead to overzealous prospective or retrospective denial of care or payment.

So, why has UM grown so much over these past few years? Upon passage of the Affordable Care Act (ACA) in 2010, health care purchasers (employers and individuals) were faced with a new set of coverage requirements and began seeking effective ways to limit the risk of potentially high financial costs. Other contributors to UM’s growth include escalating overall health care costs, increased demand for rehabilitation benefits, wide variance in care, fraud and abuse, and the medical loss ratio (the percent of the premium that an insurer spends on claims and expenses that improve health care quality, as opposed to administrative activities).

If all this seems dizzying (or more than you wanted to know), you as a consumer of rehabilitation services should know the following: typically, all health insurance payors are required to have an appeal process. This may include you as the consumer contacting them as well as your health care provider contacting the payor either by phone or by completing a form to appeal the denial decision.

The most important thing is to question your health care provider as to why services are ending if you feel it has not been explained well enough. Ask about available appeal processes if this information has not been offered. You must be a strong advocate for yourself!

 

[1] Institute of Medicine. Controlling Costs and Changing Patient Care? The Role of Utilization Management. National Academies Press, 1989.

This blog has been written in part based on information from the American Physical Therapy Association.