Behavioral Health
Training
Wexford Health’s utilization management (UM) program evaluates offsite referrals, inpatient hospital stays, and related costs. Our program covers non-urgent hospitalization pre-certification, urgent hospital certification, concurrent review, discharge planning, and prior authorization for targeted procedures. It ensures off-site services are medically appropriate and hospital stays are only as long as medically necessary.
Our UM program ensures patients with serious medical needs receive timely, appropriate services aligned with evidence-based clinical pathways. Physicians are expected to request the most conservative, medically appropriate care for each patient. If not, Wexford Health will promptly redirect requests to equally effective but more cost-efficient alternatives when available.
Components of Our UM Program
Our comprehensive UM program includes reviews before, during, and after care is provided.
- Referrals and prior authorizations (Collegial Review)
- Inpatient case management
- Readmission review
- Retrospective review
When Collegial Review was introduced at two major contracts, inappropriate referrals decreased by 30% and 25%, respectively. This demonstrates improved referral quality, with fewer inappropriate requests and denials.
The Collegial Review program uses a proactive team approach, enabling physicians to exchange ideas and share knowledge. This supports efficient resource use and cost-effective health care management.
Ensuring the Quality of Our UM Services
Wexford Health has established comprehensive policies and procedures defining all aspects of our UM process. We monitor clinician adherence, including the accuracy and effectiveness of UM nurses, as well as turnaround times for authorizations and denials. Our corporate UM Medical Director reviews and approves UM policies annually.
UM Training and Protocols
Wexford Health’s UM program includes protocols that cover decision timeliness, consistent data collection, correct use of criteria, accountability, and client satisfaction. These protocols comply with all relevant regulatory and accreditation standards. UM leaders, with input from the Quality Management Program, review and update protocols at least annually.
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