Utilization management and quality review services

Acumentra Health offers utilization management (UM) and quality review services in acute care, ambulatory/outpatient care, long-term care, home health, and mental health settings.

Utilization management and review may examine

• where care is received
• whether treatment is medically necessary
• which procedures, services, and drugs are provided
• whether care is delivered in a timely manner
• how efficiently the care is delivered
• whether the patient receive the maximum benefit from the care

Acumentra Health has contracted with the Oregon Department of Human Services (DHS), Addictions and Mental Health Division (AMH), to provide utilization management and quality review of residential and inpatient treatment programs since 1996 and to provide external quality review since 2004.

Utilization review (UR) activities for Oregon Medicaid fee-for-service programs include inpatient hospitalization utilization reviews; psychiatric residential treatment review; outcome quality reviews; analyses of claims data to identify patterns of service; and targeted reviews in areas identified for focused study.

Acumentra Health has performed inpatient hospitalization utilization review and patient outcome quality review, an analysis of claims data to identify patterns of service, and targeted review as part of its work as Oregon's Quality Improvement Organization for Medicare.

Acumentra Health has conducted quality monitoring of Washington’s home birth program as well as individual case review to investigate potential quality-of-care concerns.

Case review

Acumentra Health’s reviewers conduct medical record case review to determine whether the care received was medically necessary and appropriate. Reviews may include utilization, coding, or quality of care issues.
Healthcare professionals review, assess, and evaluate patient care processes to ensure that a practitioner provides appropriate care. Our qualified healthcare professionals include

• clinically matched physicians
• RNs who are Certified Professionals in Utilization Review
• qualified mental health professionals
• certified Registered Health Information Technician and Registered Health Information Administrator coders
• other healthcare practitioners who review cases related to their specialty

Peer review

Peer review, an in-depth review of provider medical records as follow-up to a case review, is an important component of the quality-of-care oversight provided by Acumentra Health as a Medicare Quality Improvement Organization and an External Quality Review Organization. The reviewer is generally from the same specialty as the provider that delivered the care in question.

Prior authorization and post-payment review

Acumentra Health provides prior authorization review—an assessment of medical necessity, appropriateness, and level of care before a patient is hospitalized or an outpatient procedure is performed—to clients of the Oregon DHS, Division of Medical Assistance Programs (DMAP), for specific non-emergency inpatient and outpatient admissions or procedures. For Oregon's AMH, Acumentra Health issues certificates of need for services for children and adolescents, authorizing services prior to admission to psychiatric residential treatment.

Acumentra Health also provides post-payment review services for DMAP’s Medicaid Title XIX fee-for-service program. Post-payment reviews examine services provided in hospitals or other settings after care has been provided, a claim for payment has been submitted, and reimbursement has been paid.

Concurrent review

Concurrent reviews provide information on care presently being provided and can help to determine future care needs. Acumentra Health has been conducting retrospective and concurrent review for Oregon Medicaid fee-for-service admissions on behalf of DMAP since 1984.

Retrospective review

Retrospective review provides information on whether past care was appropriate and necessary. Retrospective review has been a key element of Acumentra Health’s charge to protect Medicare beneficiaries and the Medicare trust fund as a Medicare Quality Improvement Organization and Peer Review Organization since 1984; these reviews have examined medical necessity, appropriateness of coding, and quality of care. Acumentra Health also performs retrospective review for both Oregon's DMAP and AMH.