Controlling Costs and Changing Patient Care? The Role of Utilization Management (1989) / Chapter Skim
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Appendix F - Analysis of Agreements Between Utilization Management Organizations and Their Clients
Appendix F - Analysis of Agreements Between Utilization Management Organizations and Their Clients
Pages 282-287
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From page 282... ...
Despite these limitations, several observations can be made about the content and specific approaches used in the contracts that were reviewed. CONIR\CTUAL DESCRIPTIONS OF PRIOR REVIEW SERVICES Contracts for prior review services vary greatly in length.
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From page 283... ...
Little or nothing in the contracts describes the criteria or indicates their sources. One contract states that medical review will use recognized norms and standards, of the medical need for and appropriateress of proposed, ongoing or completed medical care." Regarding hospital admission review, the most comprehensive and detailed contract stated only hat the review firm will evaluate proposed admissions to certify "medical recessity and appropriateness under the [insurer's]
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From page 284... ...
Additional provisions in two contracts have relevance to the distinction between determinations of medical need and decisions about payment of benefits. In one agreement, stated performance standards for the review organization implicitly recognize that reviewers may occasionally certify days of hospitalization that do not meet the guidelines agreed to by the organization and its client; it states that "95% of all days certified by ithe reviewers]
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From page 285... ...
For example, one contract provides that the eview organization "is responsible for maintaining during the life of this agreement liability insurance sufficient to protect it from claims of personal Jury or property damage which may arise from its activities under this agreement." The same contract also obliges the organization to require ts physician reviewers "to carry or otherwise be covered by insurance n amounts adequate to protect them against professional liability claims thick may arise hereunder." Only one of the contracts that contained an nsurance requirement specified the amount of coverage. STAFFING AND PERFORMANCE CRITERIA Purchasers of utilization management services seek more appropriate use of health services by those covered under their benefit plan.
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From page 286... ...
Most of the contracts reviewed contain little detail regarding staff. Typical is such language as "appropriate staffing levels" and "services shall be performed by physicians, registered nurses or record technicians as appropriate." Generally, references to physicians are preceded by "licensed," and references to board certification are occasionally present ~ descriptions of appeal processes.
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From page 287... ...
Two contract provisions are particularly noteworthy because they illustrate the overlap of some review organizations and purchasers in terms of their knowledge of utilization control procedures. For example, a health insurer that provides review services for some insured groups but contracts services out for others may be concerned that its subcontractor will try to solicit the health insurer's clients.
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