Utilization Management

Optimize Utilization with HELIOS

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.

One Comprehensive Member View

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.

Support timely prospective, concurrent, and retrospective reviews
Reduce the number of appeals and grievances by certifying members receive appropriate care
Provide transparency between utilization management and care management as members transition across care settings
Minimize administrative and operating costs while maximizing productivity and eliminating waste

Control the Full Utilization Management Lifecycle

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.

Authorization Requests

Authorizations are fully integrated in the HELIOS platform, whether sourced from the provider, the care manager requesting services, or a third-party system.

Auto-Approval Rules

The embedded rules engine and an extensive library of configurable clinical rules enables auto-approvals and auto-pends, distinguishes between authorization types, and supports rule hierarchies.

Medical Review Workflows

Pending authorizations are automatically routed with all necessary information available to the reviewers. HELIOS supports prospective, concurrent, and retrospective reviews.

Determination

Reviewers can solicit additional information and refer to clinical content and industry guidelines that can be configured to an organization’s specific needs. Level of care guidelines can be automated directly or via integration with industry-leading clinical content products.

Correspondence

HELIOS provides authorization-specific letter templates that can be automatically or manually generated and are automatically attached to the corresponding authorization.

Appeals and Grievances

Appeals are tied to the utilization management workflow and grievances and critical incidents can be recorded as part of integrated case management. Both are subject to reporting and configurable workflows for tracking, management, and resolution.

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:

Incorporate client-defined or third-party evidence-based clinical guidelines

Integrate with EHRs or easily leverage EHR data to trigger relevant workflows

Support and track clinical review

Monitor the timeliness of determinations in accordance with regulatory guidelines

Route requests for medical review to appropriate parties at the right time

Automate approvals and authorizations of medical services and procedures

Record the final organizational determination

VirtualHealth Utilization Management Communicate the determination to the provider and member by auto-populating configurable correspondence templates

Communicate the determination to the provider and member by auto-populating configurable correspondence templates

Capture and process any requests for additional clinical information

Auto-calculate the total cost and the total units

Conduct auto-approvals or auto-pends

Timing of Review

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.

Prospective Review

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.

Concurrent Review

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.

Retrospective Review

HELIOS for retrospective review gives users the ability to assess whether an appropriate level of care was applied after the service has been rendered.

A Better Utilization Management Process is Within Reach

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.