Prospective, Exception-Based Utilization Management

McKesson Health Solutions, February 1st, 2011

"Today is no ordinary time in healthcare. Health plan executives (plans) are facing relentless pressure to better manage costs while increasing access to care. With rising utilization and costs, members, employer groups, government entities and regulators are all demanding more affordable premiums. Larger provider organizations are driving tougher negotiations. Meanwhile, federal reform is requiring payers to expand member care by eliminating pre-existing condition and lifetime benefit limitations, adding “minimum” benefits, and including coverage for the uninsured.

"Solutions to address these challenges must help rein in cost growth while improving collaboration with providers and ultimately, health outcomes. In the past, preauthorization and other aspects of utilization management (UM) were effective in reducing inappropriate services and managing medical costs. But traditional preauthorization lacks the speed, transparency and holistic approach necessary to maximize UM effectiveness.

"The next level of UM is a prospective, exception-based model that greatly improves the impact of UM on costs while helping to ensure that the most appropriate care is consistently provided. This model facilitates real-time transparency with providers by leveraging automation and evidence-based medicine at the point of care. Enabling the consistent application of clinical and coverage rules before inappropriate services are performed ensures timely, optimal care without the administrative costs or burden of traditional programs.

"This paper details the challenges faced today using traditional authorization and discusses the advantages of a prospective, exception-based approach."

Exception based final Exception-Based-final.pdf