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Process Group
Ulitization Utilization Management
Objective
Determine over-use, under-use and misuse of benefits and take action to resolve
Optimize pharmacy use
Input
Adjudicated claims
Clinical data (pharmacy, clinical services, usage data, etc.)
Number of known patients
Output
Report on provider/prescription utilization versus alternative benchmarks that are culturally accepted
Corrective action
Update provider credentialing status
Reconciliation of capitation payment (counterbalance of utilization rates)
Identify need for corrective action based on utilization
Comparison chart of provider against peer relationship
Measurable Outcomes
X time period report (monthly) which describes admissions of beneficiaries per 1,000 and hospital days per 1,000
X time period report which describes cost per beneficiary per year
Report on beneficiary visits/1,000 to physician per year according to country and/or geographic baseline
Report on prescription per beneficiary per year
Report on procedures/1,000 per year