Improving Outcomes in Utilization Management. Module B. External
This module looks at the outside entities and processes that shape the process of UM. It begins by looking at the various government and regulatory oversight organizations, including the Centers for Medicare & Medicaid Services (CMS) and The Joint Commission (TJC)— which oversee hospitals—and the National Committee for Quality Assurance (NCQA) and URAC (formerly referred to as the Utilization Review Accreditation Commission), which oversee health plans. Next, the module looks at how hospitals typically define medical necessity, and how hospital case managers can work with health plan case managers to agree on the best care for patients—from hospital stays to single case agreements (SCAs), which are used when an out-of-network provider delivers medically necessary emergency care. Last, the module details how oversight activities can minimize overpayments and underpayments for care.