Seven Technology Features in Utilization Review Software to Control Medical Costs
Stacey Jefferson
Senior Director, Product Management
Rising medical costs are a consistent and significant challenge for workers' compensation payers. To tackle this issue, many payers are leveraging utilization review as a key tool for managing these expenses while ensuring appropriate care. Historically, utilization review was seen as necessary only in states where it was mandated. Today, more carriers recognize its value and prioritize it in states where UR is not required.
As the frequency of utilization reviews increases, the medical management software you select can give you an edge in managing claims. The best platform for your program will capitalize on efficiencies and better coordinate the efforts of medical professionals on tight schedules. How? Advanced technology.
Choosing the right utilization review medical management software can yield savings that otherwise might be missed. To help you make an informed decision, these are seven key features to look for when evaluating a medical management technology platform:
- Automation of Workflows
Customized workflows based on your internal needs and best practices will help maximize your software efficiency from intake through case closure for high touch, low touch, and no touch scenarios. - High Configurability and Flexibility
Business needs and regulatory changes are constant and unavoidable. Highly configurable software allows quick adjustments with minimal disruption, enabling you to be nimble in your operations regarding staffing, volume and regulatory changes. Avoid systems that are difficult to modify or costly to maintain. The right solution should be tailored to meet the unique needs of your organization. - Regulatory Compliance
A medical management software solution should include high automation and built-in compliance workflows designed to help UR teams make decisions that are compliant with state-mandated and jurisdictional rules. Even if your state doesn't have mandated turnaround times for reviews, having an automated but configurable due date within your workflow drives timely decisions. - Real-Time Reporting and Analytics
Don't wait until the end of the month to get answers to important questions. Monthly, daily, weekly and real-time reporting capabilities help you manage reviews and address processing concerns quickly. You want a system that can both collect and analyze data. Exporting data to other applications and generating detailed reports is essential for managing team efficiency, improving claim outcomes and assessing program improvements. - Integration Capabilities
You need real-time, secure methods for data transfer using APIs, web services and file transfers between the software, your claim system, bill review system and service providers. The medical management software you select should be able to connect to your systems to support your needs now and in the future. - Data Integrity
The ability to prompt staff for input of data elements or a system that auto-fills data at the right time in the workflow is a critical precursor to accurate reporting, compliant letter generation and correct invoicing. - Advanced Technologies
Security is vital. Your software provider should be well-versed in appropriate security methods regarding data encryption and multi-factor authentication, as well as being knowledgeable regarding advances in artificial intelligence (AI), cloud computing and using advanced software design to support your chosen UR product. When it comes to evaluating the best medical management software for your organization, not all providers are created equally. Using this checklist will help you determine what software will be most effective in controlling medical costs while ensuring appropriate and timely treatment.