Over the last 30 years, utilization management (UM) has been instrumental in assisting health plans, providers, insurers, the government and others in necessary and appropriate care for patients. UM describes proactive procedures, including discharge planning, concurrent planning, pre-certification and clinical case appeals. It can also be used to reduce medically unnecessary admissions or procedures by denying cases that do not meet criteria.

In today’s medical management system, UM services are often integrated into a dynamic “care coordination” approach that may utilize case management and disease management services as well. As UM emerged and developed over the years, it was identified by lawmakers and regulators as the tool by which health care organizations determine the type and intensity of services that their subscribers or patients receive. By regulating the UM process, states and federal governments were able to limit perceived abusive or overly restrictive practices and create a rubric through which patients obtain their benefits. Now, UM applies in virtually all health coverage contexts.

This section, created in conjunction with EBG Advisors and Schooner Strategies, reviews state health UM laws and regulations. The information focuses on several key components of these regulations, including: information on the scope, regulatory contact information, licensure requirements, program requirements, reviewer qualifications, appeals process and other relevant information. It also details many of the business, legal and regulatory forces directly impacting the medical management system, including the Affordable Care Act (ACA).

The RegQuest Utilization Management module:

  • Provides a functional summary of UM laws and regulations
  • Analyzes recent trends in the UM field
  • Includes peer review by most state regulators
  • Will be updated at least quarterly with any regulatory updates

As a result of its extensive subject matter, RegQuest’s UM module is a must have resource for health care professionals, compliance staff, benefit administrators, consumers, government officials and others who require a better understanding of the UM process.