Utilization Management Activities
|
Published: October, 2001
|
The PBH UM Committee reviews and analyzes utilization data
for individual, group and facility providers and for all levels
of care and across all lines of business. It also evaluates
member and provider satisfaction and dissatisfaction with
the UM processes. Utilization management data sources include,
but are not limited to:
- PBH Internal Utilization Reports
- Complaints and Appeals Summaries
- Member Satisfaction Surveys
- Provider Satisfaction Surveys
- Timeliness of Intake, Assessment and Referral Reports
- Provider Accessibility Reports
- Annual Audits of UM Delegated Group Practices
- Utilization Reports Submitted by UM Delegated Group Practices
The PBH UM Committee reviews the data collected against PBH
clinical guidelines, contractual stipulations, and national
and community norms to assess the performance of its providers.
Problems which appear to be quality-of- care related are referred
to the Quality Improvement Department for investigation. Utilization
patterns which are outside of the norm as established by the
UM Committee are further investigated by the UM Committee
or its designees and, when appropriate, a Corrective Action
Plan (CAP) is developed in cooperation with the provider.
Once corrective actions are implemented, follow-up monitoring
occurs to ensure that desired improvements have been achieved
and that performance continues to satisfy established criteria
and guidelines. If this process fails to resolve the problem
to the satisfaction of the UM Committee, the issue may be
referred either to the PBH Credentialing Committee or to the
PBH Peer Review Committee for further action, which can include
suspension of referrals, restriction of privileges, or termination
from the network.
Although utilization management data are used to assess provider
performance, in no instance is this data used arbitrarily
to take punitive action against a provider. Utilization data
are not used in provider profiling. When problems are identified,
PBH attempts to work in a collaborative fashion with the provider
to correct the problem, and provider input into this process
is encouraged.
Back to Top
 
|
