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Utilization Management

Wexford Health’s comprehensive utilization management (UM) program balances clinical needs with cost containment.  We identify and realize immediate reductions in inmate offsite care costs, as well as in related transportation and security costs, without creating any negative impact on the quality of patient care. 

Our program offers clients the following benefits.

  • Provides independent medical review to help ensure cost-effective, clinically appropriate care

  • Addresses all phases of a patient’s offsite encounter
    • Prospective review occurs prior to a patient’s offsite specialty appointment or inpatient stay.  By prior authorizing these non-emergent services, Wexford Health ensures that patients receive clinically appropriate care, at the right time, in the most cost-effective setting.
    • Concurrent review occurs throughout a patient’s hospital stay, in order to expedite discharge planning and produce fewer — yet equally effective — inpatient days.
    • Retrospective review occurs after a patient’s hospital visit or other emergency care, to ensure the quality and appropriateness of the services provided.

  • Includes Collegial ReviewSM, a proactive, physician-led process designed to reduce offsite care costs. Using video and/or telephone conference calls, site clinicians and Wexford Health Medical Directors and UM Nurses confer to review the patient's medical history and determine the most clinically appropriate and financially responsible approaches to inmate health care issues.  Collegial ReviewSM results in fewer requested offsite referrals, a reduction in the percentage of referrals denied as inappropriate, and an overall decrease in specialty consults.

  • Supports risk management by identifying and helping to defuse situations that may lead to litigation

  • Confirms, tracks, and provides documentation that appropriate specialty and inpatient care is delivered in a timely fashion

  • Identifies and tracks trends in offsite care utilization and costs

  • Generates scheduled, standard reports that allows comparison of client facilities with regional and/or national benchmarks

  • Offers clinical expertise for compliance with ACA, NCCHC, and other accreditation standards