Bass, Berry & Sims attorney Lindsey Fetzer provided insight in a three-part article series for HealthLeaders examining the role of utilization management (UM) in healthcare. Lindsey was quoted in the first two articles of the series.
The first article focused on the history of UM and its role in healthcare going forward. “Historically, one of the primary purposes of UM has been to address overutilization of services or procedures and address the potential for waste and/or abuse of healthcare dollars,” said Lindsey.
This article examines the tension between UM’s role in reducing cost while also ensuring quality of care. Lindsey noted: “The tensions inherent to any UM process have always been the same: the goal is to balance healthcare utilization and manage cost while also expecting that the core of any UM framework be focused on whether the service is clinically appropriate/medically necessary.”
Ultimately, Lindsey defines UM’s focus as “making sure the right care is delivered at the right time, in a way that optimizes outcomes, reduces risk of adverse clinical outcomes, and considers other data points like quality and compliance” — adding that the importance of “also controlling Medicare (and other government and private program) spend so that services can continue to be offered to future generations.”
The second article looked at the technology side of UM and how it impacts denials, automation and federal crack-downs. Lindsey noted “What’s changed is in how organizations leverage tools to arrive at those decisions [automated denials for coverage] – without undermining the need for clinical judgment and decision making.”
In speaking more about the changing regulatory landscape and the claims of insurers’ wrongful denials of prior authorization requests, Lindsey said “The regulatory landscape continues to evolve, which requires all organizations to adapt when considering the question of medical necessity.” She added, “UM processes always should focus on driving clinically appropriate decision making . . . Moving forward, we can expect continued use of UM and — in all likelihood — reliance on technology in various ways.”
The two articles in the series featuring insight from Lindsey can be found online:
- “The Many Faces of UM: A Little History,” HealthLeaders (July 26, 2024)
- “The Many Faces of UM: UM’s Dark Side,” HealthLeaders (August 1, 2024)
The third article in the series can be found here.