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Efficient UM Operations
Synova offers comprehensive utilization management programs supporting authentic clinical decisions. These programs are designed to ensure the appropriate and optimal use of healthcare resources while maintaining quality of care and controlling costs.
helps with
- Supporting clinical decision-making
- Optimizing healthcare resource use
- Controlling operational costs
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Proactive Assessment
Synova offers a proactive assessment which involves preemptive measures and strategies aimed at identifying and addressing potential utilization issues before they escalate or result in adverse outcomes.
helps with
- Identifying potential utilization issues early
- Implementing preemptive strategies
- Preventing adverse outcomes
Optimized EDI Capability
Synova’s automated workflow streamlines the prior authorization process, leading to improved efficiency, reduced denials, and enhanced revenue capture.
helps with
- Increasing efficiency in prior authorization
- Reducing denial rates
- Enhancing revenue capture
Patient-centric Care
Synova aims at prioritizing the needs, preferences, and well-being of patients throughout the healthcare utilization process. Various factors contribute towards the success of UM, including shared decision making, patient education and empowerment, and transparent communication.
helps with
- Prioritizing patient needs and preferences
- Enhancing shared decision-making
- Improving patient education
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Complexity of Insurance Requirements
Insurance companies often have complex and varied utilization review criteria, prior authorization processes, and coverage policies that can be challenging for healthcare providers to navigate.
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Evolving Healthcare Regulations
Healthcare regulations and compliance standards, such as HIPAA, Medicare guidelines, and payer-specific requirements, continually evolve and can be difficult to keep up with. Synova collaborates with compliance officers and legal experts, implements automated compliance checks within UM systems, conducts internal audits, and maintains accurate documentation to demonstrate compliance.
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Payment Denials
Denials due to Utilization Management (UM) can occur for various reasons related to medical necessity, coverage policies, documentation requirements, and adherence to UM guidelines. Utilization Management programs by Synova play a critical role in preventing denials by proactively assessing, reviewing, and managing healthcare utilization to ensure compliance with medical necessity criteria, coverage policies, and regulatory requirements.
Measurable Impact
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Optimized Resource Utilization
UM helps healthcare organizations optimize the use of resources, including facilities, equipment and supplies, by ensuring that services are appropriately utilized based on medical necessity and evidence-based guidelines.
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Cost Containment and Financial Sustainability
UM contributes to cost containment by identifying and addressing utilization patterns that contribute to unnecessary healthcare spending, such as overordering of tests, inappropriate treatments, or extended hospital stays.
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Improved Quality of Care
UM promotes the delivery of high-quality, evidence-based care by ensuring that healthcare services are provided according to established clinical guidelines, standards of care, and best practices.
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Enhanced Procedural Efficiency
Synova uses high-end software which has features such as real-time updates, notifications, and flexible architecture to meet specific requirements.
Assessment of Medical Necessity
The first step in utilization management is to assess the medical necessity of healthcare services, treatments, procedures, or medications. This involves reviewing clinical documentation, patient history, diagnostic tests, and provider orders to determine if the requested services are appropriate and justified based on established criteria and guidelines.
Authorization and Review Process
Once the assessment of medical necessity is completed, UM may require pre-authorization or prior authorization for certain services before they are provided. This involves submitting requests to insurance companies or payers and providing supporting documentation to demonstrate medical necessity, appropriateness, and compliance with coverage policies.
Clinical Guidelines and Criteria
Utilization management relies on evidence-based clinical guidelines, protocols, and criteria to guide decision-making about the appropriateness and necessity of healthcare services. These guidelines are developed based on medical literature, best practices, clinical expertise, and regulatory standards.
Continuous Monitoring and Improvement
Utilization management involves continuous monitoring of healthcare utilization patterns, outcomes, trends, and compliance with UM guidelines. This includes tracking utilization metrics, analyzing data, identifying variations in practice, and evaluating the impact of UM interventions on patient care and financial outcomes.
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Utilization Management is a process that evaluates the efficiency, appropriateness, and medical necessity of the treatments, services, procedures, and facilities provided to patients on a case-by-case basis. This process is run by — or on behalf of — purchasers of medical services (i.e., insurance providers) rather than doctors. Synova understands that members and providers require a solution that solves the time crunch and works seamlessly with their existing system to process requests on time. Our Utilization Management modules can easily integrate with your organization’s management system and solve the issues in no time.
Synova’s key components of UM include pre-certification, concurrent review, prospective review, retrospective review, case management, and discharge planning, among others.
It is important to manage utilization in RCM because resources need to be properly allocated and necessity of medical resources must be checked to save time and costs.
Utilization management impacts patient care by ensuring that patients receive the appropriate level of care based on their medical needs. By preventing unnecessary procedures and promoting efficient care delivery, UM helps improve patient outcomes and enhances the quality of care.
Synova uses some of the effective UM management strategies include risk minimization, quality assurance, patient education, and in-depth review.
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Accelerated Outcomes
Value-driven Collaboration
Compliance Assurance
Bring a change to your Healthcare Operations
A partnership with Synova gives you an inherent:
Adherence towards federal, state, and organizational compliances, as well as safeguarding patient data.
Sense of ownership and commitment towards providing value.
Focus on speed, accuracy, efficiency, and optimal outcomes.
Sense of security and transparency through periodic reporting and actionable insights.
Connect with our experts for a quick analysis and possibilities.
