You may remember the two extremes depicted in the 2008 presidential election regarding health care. We heard health care proclaimed as an inalienable "right" of sorts. Politicians would ask their constituents polarizing questions like, "Is health care a right for all Americans?" or, "Is it a privilege to which only the wealthy minority are entitled?," as if these two extremes were the only positions that a health care stakeholder (consumer, provider or carrier) might have on such a complex topic.

These are the absolutes of health care; they feel a bit like the "I always" and "He never" phrases we are taught to avoid in personal relationships.

Enter utilization management. My experience with UM is that most of us do hold our access to prescribed treatment as an inalienable right. Inserting a utilization manager between a consumer and treatment his doctor prescribed can turn your health plan's biggest fan into a vocal, dissatisfied customer faster than you can say "medically necessary."


Plan participants hate it

There is no spectrum, only the absolute: Plan participants always think utilization management stinks. They never appreciate it. Period.

Our health plan is self-insured and self-administered. We are a "Minnesota Nice" company. Our claims team works hard to find a compliant way to pay claims whenever possible.

We have, however, identified a list of covered services that require precertification for medical necessity and standard of care - including hospital stays, therapies, equipment and scans. If a patient doesn't call to precertify, they'll pay a penalty, even if the service is ultimately deemed necessary and appropriate. We've contracted with an external utilization management company to administer the related processes.


Counting down UM absolutes

I'm sure the people who work for our UM company are very nice, but they are anything but popular with our employees. Their involvement with our plan has burned a top 10 of absolutes into my brain.

No. 10: UM is for "other" people.

Participants will acknowledge that they understand how the process helps contain cost and prevent abuse and excess utilization. But they will go to great lengths to explain why their scenario is different - usually because they've been low-cost care users and/or "good soldiers" up until now.

No. 9: My doctor is infallible.

Most people don't want a second opinion to help validate the expensive treatment a doctor has ordered. "I trust him. Everybody trusts him. Why don't you trust him?" is the common refrain.

No. 8: Nobody else requires this.

We hear this about our precertification requirement for expensive scans such as MRIs, CTs and PET scans.

No. 7: This takes too long.

We pay a vendor to provide a turnaround of seven to 10 days. Patients are frustrated when they cannot get treatment approved as "medically necessary" within hours of placing a call to the utilization management vendor and before the vendor has even received the medical records needed to make a determination.

No. 6: You've got a lot of nerve!

We hear this about our precertification requirement for therapy and rehabilitation services. Our plan doesn't limit these in any way, and the second opinion helps ensure medical necessity and curbs excess treatments. It is not unusual to certify fewer sessions than the doctor requests.

No. 5: Precertification overload.

Fear about getting a precertification penalty will result in a degree of paranoia for the super-astute. They'll call the UM vendor on a routine office visit and be frustrated when they're told, "You didn't have to call for this."

No. 4: "Everyone" knows about the precertification woes of cancer patients.

The field of oncology is constantly changing. Chemotherapy regimens are not routine. Experimental treatments are intermixed with more established therapies. Doctors change courses of treatment midstream all the time, and thus don't want to precertify too much of the treatment plan at a time.

There is great risk of claims being denied as "experimental" or not medically necessary. Precertification can help avoid the risk of significant denied claim expense and/or pursuit of other, covered options.

But the process is seen as an intrusion and unnecessary red tape by people who are really suffering. Cancer patients amaze me. But their family and friends will get offended on their behalf. You'll hear from them.

No. 3: I've got a golden ticket.

It doesn't matter how often you say that precertification of a service isn't a guarantee of claims payment (that's a different process), people will assume a green light from the precertification vendor is a guarantee of payment. Sadly, some find out it's not.


Providers hate it, too

No. 2: Providers hate utilization management.

Doctors, hospitals and theirs staff are busy. Extra paperwork and the need to provide enough detail to a UM vendor to make a medical necessity determination is a huge pain in the neck. They will be quick to blame your UM vendor instead of acknowledging that they didn't provide the required information.

They will do nothing to enhance your participants' perspective on UM. They will pour gasoline on the "Nobody does this" flame. Who can blame them? Who likes to have their professional opinion and/or decisions questioned?

No. 1: Utilization management saves money.

Even though most precertified services are ultimately approved as necessary (and later paid), you do catch that pesky 10% of prescribed services that aren't.

We've definitely seen cases where a provider was quick to withdraw a recommendation for an MRI when her rationale was challenged. This can amount to significant dollar savings for your plan and, ultimately, the participants.

Plus, the "sentinel effect" of a UM vendor likely curtails unnecessary treatment from being requested or ordered in the first place.

So where do we land with utilization management? It's not absolutely good, and it isn't absolutely evil, either. Is it worth the aggravation? So far, our answer is yes. So, we take our lumps and do our best to educate our members on the why, what and how of utilization management.

Contributing Editor Cindy Bucher is the benefits and compensation manager for a Midwestern financial services company. She and her staff serve more than 2,500 active employees and 650 retirees, as well as their families. She can be reached at

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