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Utilization Management System

  • To combat continually rising workers' compensation costs, the health care environment continues to migrate towards more rigorous standards of evidence-based practice. In order to facilitate the consistent delivery of evidence-based rehabilitative treatment, the Select Medical Outpatient Division has designed, developed and deployed a Utilization Management System (UMS) that is the cornerstone of its cost containment program.

    UMS Goals: 

    • Align provider practice patterns
    • Provide a predictive model for utilization
    • Establish clinical benchmarks for provider evaluation and management
    • Facilitate return-to-work and cost-savings

    In order to overcome limitations in commercially available guidelines, we have created a proprietary guideline set for the management of rehabilitation in the workers' compensation arena. Guidelines are based upon nearly one million unique episodes of care and are risk adjusted to include:

    • Diagnostically-related groups
    • Age
    • Surgery status

    Features: 

    • Peer-to-peer clinical management/mentoring
    • Concurrent assessment of medical necessity
    • Delivery of evidence-based care with appropriate services, frequency and duration
    • Prospective discharge planning
    • Objective provider performance analysis
    • Predictive modeling
    • Proven cost-savings

    Benefits: 

    By utilizing diagnostic-specific benchmarks with established performance parameters, we are able to assist companies with historical analysis of past claims to determine effectiveness of rehabilitative services, and provide prediction of future utilization and healthcare costs. This enables companies to more accurately set medical reserves, as well as evaluate the network's performance in facilitating a quicker return to work and reducing the overall cost of care.

    Please contact the Utilization Management Program with any questions.