Medical Management/Quality Assurance/Utilization Review

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Medical Management/Quality Assurance/Utilization Review Standards

The goal of the program is to ensure that members receive appropriate, cost-effective care rendered by high quality providers. This goal is achieved through continual monitoring of treatment plans, provider credentials and provider performance.

The program is a URAC certified utilization review program and utilizes InterQual criteria for procedure review.

Medical Management/Quality Assurance/Utilization Review Examples

  • Moving an outpatient procedure to a physician’s office or free standing facility when clinically appropriate
  • Outpatient surgery when feasible
  • Alternative treatment services such as home care and home infusion therapy
  • Relevance of health care services to the medical needs of the patient based on age and clinical diagnosis
  • Services consistent with the clinical impression or working diagnosis
  • Appropriateness of treatment frequency and demonstration of compliance with evaluation and management coding guidelines
  • Use of other health care services consistent with the patient’s medical needs
  • Use of appropriate CPT codes and guidelines for visits, consultations, and treatment of the condition described
  • Detection of duplication of diagnostic procedures
  • Determination of provider compliance with managed care requirements
  • Performance of procedures in a manner consistent with FDA or other guidelines and community standards
  • Utilization of resources commensurate with burden of illness

Peer Review

Reviews of provider behavior will be performed by similarly boarded physicians, including both BHN medical directors and external practitioners.