JLN Process - Utilization management (process)

Process Group

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

• Length of stay (LOS)

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

Sources

• Joint Learning Network, 2012

• File: NHIIS_Phase_1_Public_Report_JLN_IT_Workshop_FINAL_Jan182012_A4.pdf