Utilization management is the evaluation of the appropriateness and medical necessity of health care services, procedures, and facilities according to evidence-based criteria or guidelines. HELIOS was developed to reduce the administrative burden of utilization management. The automation of authorization-related processes, and integration of data into payer’s and provider’s workflows can significantly reduce the manual work involved in following up on authorizations requests, as well as helping eliminate redundant workflows. For utilization management, the HELIOS platform enables the development of improved policies, high-performing networks, and targeted provider interventions.
To promote value-based care within utilization management workflows, payers and providers must be able to easily collaborate at the point of care. Administering the right care in the right setting means that providers need to be able to access relevant data. HELIOS provides a single unified platform for UM reviewers, including Registered Nurses, UM program managers, and medical directors to see a full view of a member. This single unified view includes their clinical care history, case notes, evidenced based approaches and treatments, member’s insurance benefits, and provider networks. Additionally, activities at the provider level include automated workflows and streamlined availability of data that enables medical directors to make the most informed decisions possible.
HELIOS provides an integrated solution that streamlines all major components of the utilization management lifecycle from authorizations to appeals and grievances, while ensuring the determination of any medical service is based on evidenced-based practice and a complete 360° degree view of the member.
HELIOS can be used on a standalone basis to provide the complete workflow for both episodic and chronic service authorization requests or integrate with a third-party system. The platform can be deployed with utilization management criteria frameworks including McKesson’s InterQual and MCG. Additionally, clients can configure HELIOS with the medical guidelines developed in-house.
The workflows can be tailored per group or product line to enable providers and care team members to electronically submit authorization requests using a customizable form that can:
Utilization management helps to ensure that providers are maintaining a high quality of care and administering effective treatments while minimizing costs. HELIOS supports prospective, retrospective, and concurrent reviews. It can be used to improve the working relationship between providers and payers, registered nurses, and care and case managers.
Conducted at the onset of a service or treatment, HELIOS helps clients perform precertification or prior authorization to reduce unnecessary services. Utilizing HELIOS for prospective review can reduce medically unnecessary admissions and procedures and direct members to more appropriate care settings prior to a service.
Performed during the course of treatment or episode of care, HELIOS for concurrent review provides clients with the ability to perform extensive case management activities that include care coordination, discharge planning, and care transitioning. Users of the platform can carry out concurrent review as part of the clinical workflow to reduce denials and place the patient at a medically appropriate point of care.
HELIOS for retrospective review gives users the ability to assess whether an appropriate level of care was applied after the service has been rendered.
Technology and platforms that fit within a collaborative ecosystem of payers, providers, and vendors across the care continuum can improve the process of utilization management. Increased automation of the authorization process will reduce administrative costs, make authorizations more timely, and ensure appropriate care with better outcomes.