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 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. The HELIOS® platform also allows providers to directly submit authorization requests.
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 evidence-based guidelines 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 Change Healthcare's InterQual clinical decision support and MCG's care guidelines. Additionally, clients can configure HELIOS® with the medical policy 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.
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.