Health Network Solutions, Inc. : Utilization Management

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utilization management / Quality improvement programs

Utilization Management (UM) is part of the concept of "managing care" and is one of several functions delegated to HNS. Utilization reviews provide valuable information regarding the utilization patterns of our network providers as it relates to the costs of health care. Keeping network utilization patterns within the range of acceptance is not only a network management responsibility; but since it helps to control costs, it can be a significant factor in determining future reimbursement from contracted payors for chiropractic services.

HNS has chosen to fulfill its utilization management responsibility retrospectively. Our Provider Utilization Management program allows our providers an opportunity to establish utilization patterns based upon their own clinical judgments and compares their utilization patterns only to the practice patterns of their peers in the HNS network. This means that our range of acceptance for utilization patterns for the 3 listed categories (below) is based solely on the collective practice utilization patterns of ALL network provider

Payors also track physician utilization patterns and HNS often meets with the Medical Directors and/or QA Committees of our contracted payors to compare the results of the HNS Provider Utilization Management program with the results of the payor utilization reviews.

Our UM program is designed to help our providers be aware of and understand utilization management, to provide an opportunity for our network providers to see how their own utilization patterns for the 3 categories listed below, compare to their peers in the HNS network, and to provide a better understanding of how such information is viewed by the payor. We also offer education and assistance to those providers whose utilization patterns place them at risk.

Since our UM program is a retrospective program, our review is conducted annually and reports are sent to network providers by the end of the first quarter of each calendar year. Network providers who wish to check their current UM status can obtain this report at any time during the year, (after the first quarter of each calendar year) by simply contacting their HNS Provider Representative.

Our annual UM report compares each HNS provider to his/her colleagues in the HNS network only for the following three categories:

Average Number of Visits per Patient
Average Total Allowable per Patient
Average Total Allowable per Visit

Participation in our utilization management program is mandatory for all network providers and our utilization reports identify those providers whose utilization patterns in these 3 categories are outside of the HNS network averages.

Providers whose UM reports indicate that they are outside the range of acceptance, when compared to their peers in the HNS network, are not cost effective in the delivery of chiropractic care. Such providers risk termination from the HNS network. However, those providers will be given appropriate time to improve their utilization patterns to within the range of acceptance before any action is taken. Such providers are urged to contact Dr. Steve Binder, Chair of the HNS Quality Improvement Committee, for assistance in bringing utilization patterns in these categories into acceptable range. To obtain his contact information, please contact your HNS Provider Representative.

It is also very important to remember that HNS individual provider UM reports do not prevent or protect you from post- payment payor audits! These reports only compare your utilization in the 3 relevant categories, with your peers in the HNS network. To protect against post-payment audits, all participating providers must assure that their health care records establish clear medical necessity for all services billed, comply with payor corporate medical policies, HNS documentation, coding and compliance policies, as well as any guidelines or rulings issued by your state licensing board, and all state and federal regulations.

Quality Improvement - Credentialing and quality assurance reviews may occur periodically and/or at the the discretion of HNS.

Requests for Records

Occasionally, HNS must request copies of health care records for patients whose claims have processed through HNS. Records may be requested to investigate a payor or member complaint or allegation or may be randomly requested to assure compliance to HNS and payor policies. Network providers must promptly comply with such requests. If HNS conducts a review of health care records for members whose claims process through HNS, HNS will provide the physician with a written analysis of the review of the health care records.