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Utilization Management

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MedPOINT’s Utilization Management Department encompasses three main areas: outpatient review, inpatient review, and case management (described in more detail; see below). Essentially, the utilization management umbrella is designed to ensure consistent care delivery by encouraging high quality of care in the most appropriate setting from our highly qualified provider network. The patient’s clinical information is collected to determine the level of care needed and that the proposed treatment is medically necessary. Members of the health care team follow the patient throughout the healthcare delivery system and ensure that appropriate facilities and resources are utilized.

Department objectives include establishment/implementation of written UM protocols and criteria applicable to medical necessity review, providing alternative suggestions of treatment to the practitioner, concurrent review of all in-patient hospitalizations, discharge planning, evaluation of practice patterns along with identification of care variation, and assuring that regulatory turnaround times frames are met or exceeded. We are also proud of our transitions of care and after-care clinic programs.

Central to our review process is the availability of board-certified physician reviewers in key specialty areas. This advantages us to provide our members with the most current medical information available in order to make the best decisions.

Providers are encouraged to use MedPOINT’s web portal to request authorizations and look up other information. Once the authorization is completed, a print screen is available for posting in patient charts. Specialist notes and other pertinent information is also attached to the web profile.

MedPOINT, on behalf of its contracted IPAs, will make available to its members and practitioners, upon request, verbally or in writing, information about its Utilization Management Program, including a description of the Quality Management Program/Plan and a report of progression toward meeting its goals.

Members and Practitioners may obtain copies of criteria used to make Utilization Review decisions by calling (818) 702-0100. The Medical Director and other UM personnel are also available to accept collect calls from callers who have questions about the UM process by calling (818) 702-0100.

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