Utilization Management

The AveCare Utilization Management module supports a variety of utilization review functions for both inpatient and outpatient services, including

  • Precertification,
  • Prior authorization,
  • Administrative notification
  • Concurrent review, and
  • Discharge planning

Coding and Criteria

To facilitate review intake, both CPT and ICD9 codes and narratives are searchable at point of entry; and, for admissions/services that require clinical review, the system supports the integration of client selected clinical criteria and length of stay information into the review module. The criteria is accessed either through the entry of a diagnosis/procedure, or through a general lookup function. Any available electronic criteria can be mapped into the system.

Case Management and Disease Management Alerts

During the review process, the utilization review module automatically indicates if a patient has been assigned to a case manager or disease manager, so that reviews can be forwarded to the appropriate personnel for handling; it also indicates all queue (“to do”) entries currently in effect for the patient.

The module also has the option to use an internal “trigger” list of diagnoses to identify patients that may require further intervention through case management, disease management, or quality management. Once a diagnosis is entered in the system for a review and it matches a diagnosis on the list, a message appears giving the reviewer the option to flag this patient for case management, disease management, quality management, or as a potential “large claim”. Reports may be produced for potential “large claims” for internal use or for notification to insurance carriers and reinsurers.

Automated Referrals
In addition, the module provides automated referral for physician/supervisory review (including setting up a queue or “to do” entry for the reviewing entity). 

All reviews and referrals are time/date stamped so that compliance with regulatory and certification timeframes can be monitored and reported.

Once a review is completed, automated customizable letters are produced directly from the application so that timely notification can be rendered. The system provides a historical log of all letters sent that includes all of the variable information contained in the letter.

Additional Functionality

The following system-wide functionality also supports the utilization management function:

  • The contact screen allows the reviewer to track all the outgoing and incoming contacts made on a patient, along with the outcome of each contact.  Activity reports can be produced to show a complete record of contacts for a patient.
  • The queue screen provides a To Do list with automated follow-up notification for reviewers, supervisors and physicians to manage their workflow. The screen tracks each phase of disease management with follow-up dates to insure compliance with internal timeframes. Management can track the case load and turnaround times of each reviewer by accessing the Queue Screen or by running reports. Supervisors and managers can also transfer cases from one reviewer to another.
  • The note screen stores free-form and client-specific notes related to disease management services. The application tracks notes by category type, date written and reviewer; and it has a “pick list” option that will automatically insert selected wording that a client has created based on sentences and phrases commonly used.
  • The billable hours screen, accessible from any system module, provides each user a single location for the posting and tracking of billable time/activities.
  • The physician and facility screens provide ready access to key physician and facility information in support of utilization review activity, including provider demographics and network affiliations.

With AveCare, utilization review is a fully automated online process that allows clinicians and support personnel to efficiently and effectively handle review activity.