It is the philosophy of Cap Management Systems that for an IPA to be successfully managed, medical utilization must be proactively managed rather than just tracked and reported. The CMS Utilization Management Department uses clinical criteria that augments the physicians’ practices and maintains appropriate controls of the referral process. CMS has processes that allow staff to authorize standing referrals for chronic conditions to avoid disruption in patient care. Utilization review functions are limited to those areas of care that are prone to result in unnecessary or inappropriate patient treatment as well as identifying members who may need care coordination due to the severity or complexity of their conditions.
CMS also provides clear and concise trending reports that monitor provider performance as well as IPA performance compared to community standards. CMS is also able to create group specific processes that focus the Utilization Management Committees on key areas of concern, while ensuring compliance with all health plan and regulatory standards.
|