UM is an important, systematic process that promotes efficiency in healthcare.
When performing UM, care managers consider the following factors to determine the appropriateness of care for a member:
- The severity of symptoms, acuity of symptoms, prior treatment efforts, clinical diagnosis, and level of impairment in functioning.
- Clinical outcomes research and level of care guidelines.
- Capabilities of local providers and facilities.
This ensures that members get appropriate and necessary care in the right setting without redundant or unnecessary procedures.
This, in turn, helps payers control costs and prevent both under and over-utilization of services.