Utilization Management

Implementing a strong utilization management program assures that patients receive the right care at the right time.

It also ensures that providers deliver appropriate, cost-efficient care.We perform a detailed clinical analysis to determine whether we can save you money while providing your members with the same or better level of service. To ensure our members receive the right care at the right time, we review cases throughout the continuum of care:

Prospective Review

Before authorizing treatment, we evaluate the medical necessity and appropriateness of care.

Concurrent Review

During the course of treatment, we intervene on coordination and transition of care and on discharge planning.

Retrospective Review

After treatment, we will assess the appropriateness of the procedure and relocate recurring treatments to better, lower-cost settings.

Utilization management success story

A MagnaCare member with a rare disorder was receiving a routine specialty infusion in a hospital setting. After speaking with the member, MagnaCare’s expert Medical Management staff helped move the member to home infusions, administered in the evening by a visiting nurse.

The site-of-service relocation not only lowers costs, but also enhances the quality of life of the member, who receives this necessary therapy in the comfort of home, without the need for the long drive to the hospital and without missing work.