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Utilization ManagementPrairie States' Utilization Management focuses on working with members during an acute phase of illness which may require hospitalization to obtain the appropriate services. The goal is to assure that patients receive the most effective treatment in the most cost-effective manner. Active involvement by Prairie States’ nurses during treatment ensures that best practices are followed, and prevents redundant procedures and unnecessary costs.
Prairie States' clinical advantage is the key to savings
The program is performed by experienced Registered Nurses and supported by a full panel of physician specialists. Utilization Management integrates pre-admission certification, concurrent review, second surgical opinion, and discharge planning, with our nurses reviewing both inpatient and outpatient services. We identify questionable practices or procedures that are problematic, and evaluate for criteria that determine medical necessity. We look for alternatives to shorten hospital stays while providing necessary treatment using best practice guidelines.
Utilization Management's impact
Active involvement by Prairie States' nurses and clinicians during treatment enables employers to keep claims costs under control while ensuring that employees and their families receive the best care for their illness. Not only does our monitoring reduce claims costs, the stop loss carriers serving our customers provide significant premium discounts to our customers because of their faith in our Utilization Management service. What sets us apart is integration: all of our utilization management is performed in-house. With the claims history and the nurses' clinical data all on the same system, there is never any loss of data or time lag because there is never a “hand-off” to an outside service, permitting us to get involved right from the beginning.