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Integrating Utilization Management and Case Management With Medical Benefits: How (and Why) It Works

By Heather Kerrigan | Oct 31, 2018

Members often struggle with the delicate balance of finding the right providers and treatments without breaking the bank. One way to help is to consider integrating utilization management and case management into the medical benefits you offer.

With these tools, members gain access to advocates and techniques that can help them navigate the health care system, preventing unnecessary medical treatments and ensuring they receive the appropriate level of care. This can result in cost savings for both members and the union — and lead to better overall health outcomes.

Utilization and Case Management

Utilization management is intended to control health care costs by evaluating the appropriateness and effectiveness of care. Precertification of benefits is a common utilization management tool that allows members to contact their insurance company to verify that a specific procedure or treatment is covered under the insurance plan. The insurance company also uses health metric data — including procedural outcomes, timeliness and recovery time — to determine whether or not a treatment is medically necessary. These measures are aimed at improving care and reducing costs — not by preventing members from accessing treatment but by ensuring that the treatments used are appropriate and cost-effective.

Case management is the process of researching, planning, facilitating and coordinating members' health care needs. This includes identifying the services members require and then matching them to the sources best able to provide this care in a cost-effective manner. Case managers can work directly with members to help them find the best resources, providers and facilities to meet their medical needs. Case managers also act as patient advocates, ensuring members are discharged from the hospital at the right time and receive the correct prescription dosage, among other things.

The Benefits of Integrating Utilization and Case Management

Utilization management can reduce waste, prevent unnecessary medical procedures and encourage greater use of medical interventions that have proven to be effective at meeting a member's health care needs. Assessing and speaking with members about their options means they're less likely to undergo unnecessary procedures, both saving money and avoiding treatments that could lead to complications. Similarly, case management drives health outcomes by allowing for better coordination of care. Members gain peace of mind because they're supported in their medical decisions, while both board members and medical professionals can relax knowing that a case manager is helping ensure that members comply with medically prescribed treatments and self-care plans.

To further cost savings and better care outcomes, the board can use the data and trends collected through its utilization and case management services to monitor and assess member usage of plan benefits and develop the best offerings for the future. Regularly reviewing, monitoring and adapting health care plans is ideal for coordinating care and saving money.

Beginning an Integration

Before starting any integration, the board should determine whether or not the union's health insurance provider has resources dedicated to utilization and case management. If these services are available, then you can find out what they offer and at what level. Some baseline questions to ask include:

  • Can members take advantage of precertification, second opinions and case manager referral?
  • If so, do these services apply only to medical benefits, or do they extend to behavioral and psychological care as well?
  • Does the insurance company offer case management to members with more complex chronic medical conditions, or is it provided only for those with more routine medical needs?

The answers to these questions, along with an analysis of the board's current health plan usage, should determine what best fits members' needs.

Once the board has started integration, it can begin outreach to explain what utilization and case management offer, why they're important and how to leverage these services. Effective communication is key — members shouldn't feel like they're being prevented from accessing the services their doctor has identified as medically necessary. Instead, make it clear that the union wants its members get the right care at the right time.

Bringing utilization management and case management together can be an effective way of guiding members toward a more cost-effective use of their health insurance benefits without losing the focus on keeping members healthy and happy. When integrated with medical benefits, these services will identify and address inefficiencies, making sure that members get the best care for their specific needs.

Heather Kerrigan started her career in journalism at Governing magazine, reporting on state and local politics and policy, with a specific focus on public workforce, environment, health care, education and technology issues. Prior to co-founding River Horse Communications, Heather offered freelance editorial services to a variety of outlets, including serving as volume editor and lead author for SAGE Publications' Historic Documents series and editor-in-chief of The Kanter Journal. Heather also blogs for two government-focused publications, GovLoop and NEOGOV, covering issues of importance to federal employees. Heather is the author of the book Retire Rich With Your 401(k) Plan. She holds a bachelor's degree in journalism from The George Washington University.