All of this information is included in your member handbook that your insurance company provides so take the time to familiarize yourself with these processes so you are aware of your rights. Physicians and providers are also well aware of the rules and the process as part of their agreement when they become contracted to a managed care network.
The role the patient plays in the utilization review process is important as your input can help your
- Understand the treatment recommended
- If there is more than one treatment option, all options should be explained to the patient by the ordering physician so the patient is given the opportunity to choose the options that best meets their goals. This process is known as shared decision making.
- Understand if the treatment being ordered and how it will make a difference in your care
- Understand what the test show or treatment will show or do to improve your care?
- If you don’t get the treatment, what are the consequences to your condition or life?
- Are their complications associated with the treatment to be aware of?
- What costs will the you be responsible if the treatment is approved? You may have a co-payment to make if/when the treatment is approved.
- Your doctor should be able to answer all of these questions so you can be sure the treatment plan is understood by you. If your physician does not provide the answers to any of these questions, you should question the plan of care as having answers to these conditions are critical.
Appropriate Use of Medical Resources: TheAmerican Hospital Association provides information that will explain what Utilization Management is and why it is used today to improve care and control health care costs. Here is the link to access the information. http://www.aha.org/advocacy-issues/appropuse/index.shtml
The Role of Utilization Management in Case Management: This article shows that a priority of every case management intervention is to support the patient to make sure that they are getting the best care and support over a continuum of time to achieve positive clinical outcomes. http://www.cmsa.org/Individual/NewsEvents/HealthTechnologyArticles/tabid/649/Default.aspx