Naya Kehayes, managing principal and CEO of Eveia Health Consulting and Management, recommends hospitals and other providers ask payors these 10 questions regarding utilization and management procedures within managed care contracts during negotiations.
1. Is the basic utilization-management structure defined?
2. Is the utilization-management administrator identified? Are procedures regarding adverse decisions and payment over adverse decisions clearly defined?
3. In instances when utilization-management review is not delegated, are policies and procedures regarding record reviews and on-site reviews clearly defined? Are they reasonable from the standpoint of the provider?
4. Is the provider obligated to any additional reporting requirements in connection with utilization-management? If yes, how extensive? Is the payor willing to compensate for extraordinary requirements?
5. Are utilization-management requirements clearly discernible; for example, are they noted on the subscriber's identification card? Are utilization-management categories properly defined, such as concurrent or emergency admission?
6. Can retrospective denials be imposed?
7. Are there any utilization-management penalty provisions? If yes, how extensive?
8. Is the utilization-management plan available for review?
1. Is the basic utilization-management structure defined?
2. Is the utilization-management administrator identified? Are procedures regarding adverse decisions and payment over adverse decisions clearly defined?
3. In instances when utilization-management review is not delegated, are policies and procedures regarding record reviews and on-site reviews clearly defined? Are they reasonable from the standpoint of the provider?
4. Is the provider obligated to any additional reporting requirements in connection with utilization-management? If yes, how extensive? Is the payor willing to compensate for extraordinary requirements?
5. Are utilization-management requirements clearly discernible; for example, are they noted on the subscriber's identification card? Are utilization-management categories properly defined, such as concurrent or emergency admission?
6. Can retrospective denials be imposed?
7. Are there any utilization-management penalty provisions? If yes, how extensive?
8. Is the utilization-management plan available for review?
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