Utilization Review/Management

For more than 30 years, HSAG has been performing utilization review of health care services to ensure that patients receive optimal medical care that is medically necessary and delivered in the appropriate setting. Utilization review may be performed before, during, or after the provision of health care services, and includes precertification as well as concurrent and retrospective case review. HSAG has extensive utilization management experience, having reviewed more than 300,000 medical and surgical cases for medical necessity, appropriate level of care, and coding accuracy.

HSAG is accredited by URAC, a nonprofit organization promoting health care quality through accreditation of health care organizations’ utilization review programs. While providing utilization review services for customers, HSAG follows URAC- and customer-specific guidelines regarding benefits. In addition, HSAG conducts appeals reviews from providers and consumers when insurance benefits come into question.

The list of clients that employ our utilization review services are: 

• AHCCCS Medicaid FFS Program—Since 1983, HSAG has contracted with the Arizona Health Care Cost Containment System (AHCCCS—Arizona's Medicaid program) to safeguard against unnecessary or inappropriate use of Medicaid services and to assess the quality of those services in accordance with 42 CFR Part 456. HSAG conducts 9,000 reviews per year related to continued stay, quality of care, and medical necessity.
  
  
• Self-Funded Employer Groups—HSAG contracts with self-funded employer groups to provide utilization management services following URAC and customer-specific guidelines regarding benefit structure. HSAG performs approximately 5,000 services per year, including preauthorization; concurrent, retrospective, case management, and focused reviews; and consulting services. HSAG uses InterQual criteria for preauthorization, concurrent, and retrospective reviews. In addition, HSAG physician advisors make final recommendations regarding medical necessity. Comprehensive reporting of activities includes status and activity reports, along with quarterly and annual utilization management reports.
  
  
• External Peer Review Services—HSAG's panel of over 150 experienced physician reviewers—board-certified in more than 40 specialties and subspecialties—provides comprehensive quality and external peer-review services to hospitals, ambulatory surgery centers, and managed care organizations around the country.