A new technique for monitoring utilization review performance

Article Abstract:

Utilization review (UR) programs for medical care must be monitored regularly to assess their performance value. The performance of UR programs should be checked because their effect on utilization and expenditures do not last long and do not always work at maximum levels. To monitor UR performance, clinical indicators which are conditioned by the program must be observed closely. Accounting for these indicators which represent utilization rates and percentages affected by the program provides a low-cost technique for checking the program and guaranteeing investment return.

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ERISA preemption applies to utilization review decisions

Article Abstract:

Health benefit plan usually employs the effective utilization review (UR) to minimize costs. Several court cases, however, have highlighted the potential legal liability risks for plan sponsors who use UR. In Corcoran v. United Healthcare, the court limited the liability of the ERISA plans and their UR organizations by preventing the plaintiff to be paid for thedamages allegedly arising from a faulty UR decision.

Cases

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Demanding exceptional service in managed care

Article Abstract:

Employers can demand service requirements from healthcare providers by using a 'check-up' model instead of just relying on vendor reported data and annually negotiated service contracts. The check-up list should include plan performance in areas such as provider choice and access, consumer satisfaction, and administrative efficiency that would aid performance appraisal of vendors.

Employee Health Benefits, Health insurance, Employee benefits

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