Utilization Review (UR)

 

Utilization control is a way insurance companies monitor economy of care and manage the appropriateness of admissions and continued care.  A case manager, representing the insurance company, will make an assessment of medical necessity for the client based on progress, diagnostic criteria and statistical reports.  They are interested in programs and services being offered by providers.  Diagnostic criteria is a significant focus of case managers during a UR.  They will also be comparing level of care and duration with average lengths of stay for similar diagnosis.  As you can see this is an arduous process and directly impacts decision associated with care. Following every utilization review, Illuminate provides a Number of Days Authorized (NDA) report, indicating the UR outcome with any limitations, requirements, instructions and other detailed information.  We pride ourselves on effective communication with our partners.

 

Illuminate has worked with treatment centers to refine and strengthen their documentation, recording strategies and assessment processes to ensure the most appropriate duration and level of care for individuals in treatment.  We want to be an extension of your business, working towards increase profitability and care together.


Illuminate Billing Advocates has relationships with insurance case managers and has negotiated many utilizations reviews successfully to maximize care and provide individuals with the vital treatment services they need.  We are here to reduce frustrations and increase your ability to help clients heal.  Statistics indicate that roughly 10 percent of individuals needing substance abuse treatment actually get it.  Let us help increase that statistic.

Level of Service

 

A reputable billing service will understand levels of care, medical necessity, diagnostic criteria and have professionally trained staff.  The staff at Illuminate Billing Advocates consists of professionals in the field of substance abuse and mental health with years of specialized experience.  Our billing specialists are trained and attend continuing educations classes to stay on top of changes in the medical billing world.  We are also proud of our executive business team that provide the structure and leadership seen in successful businesses.

 

Mental health is a complex time intensive service, covering a broad scope of health care needs for individuals from every age, gender and socioeconomic group.  The range of services within the mental health umbrella include acute and chronic issues, mental and social health concerns with divers levels of severity.  Coverage for diagnosis and treatment vary widely at the state and payer level.

 

These complex services require trained professional on many different fronts from medical billing, providers of mental health service, the facilities where these services are performed and the payers of medical benefits.  Billing professionals in a rapidly changing environment must be trained and able to tackle complex challenges as the field of medical billing negotiates technological changes.

 

 

  • Levels of care knowledge

    • Substance abuse detoxification

      • Inpatient Residential

      • Inpatient Acute Care

      • Inpatient Detox

      • Ambulatory Detox

    • Residential treatment for substance abuse disorders

    • Partial Hospitalization

    • Intensive outpatient programs

    • General outpatient programs

    • Community based programs

 

Substance abuse detoxification:  Detox is typically the first step in recovery.  Allowing time for the drugs to leave the body, manage cravings, withdrawals and help the brain return to a level of “normal” functioning.  The level of care for detox is dependent on the degree of use, type of substance and duration of use.  The required support will be assessed at the beginning of treatment by a licensed and qualified clinician or medical provider specializing in substance abuse treatment.  Detox can take several days to a few week in some cases.  The goal of detox is to manage withdrawal symptoms.  Therapy and other forms of treatment are less effective during detox due to the symptoms associated with this stage of recovery.

 

Residential treatment:  Research supports the effectiveness of residential treatment of substance abuse.  Clients are provided with 24 hour care and evaluation as the recovery process continues.  Residential care is for individuals who have had multiple, unsuccessful attempt at recovery, in outpatient settings, and often have other mental health challenges needing intensive, round the clock care to achieve lasting change.

 

Partial hospitalization programs:  Partial hospitalization helps integrate individuals back into the community and daily living as a way of practicing their new skills and coping strategies while still in a supportive structure.  This gives opportunity to address triggers and challenges as they occur and create strategic plans for handling these challenging situations.  This level of transition has proven to be effective in the treatment of persistent substance use disorders.

 

Intensive outpatient program:  IOP (Intensive outpatient program) care can also enable people in recovery, to continue their recovery therapies on a part-time, yet intensive schedule, designed to accommodate re-engagement in work and family life.  Intensive programs can start at 5 days a week and taper down to 3 days a week, 6-8 week in duration of individual and group therapy sessions is typical.  Experiential groups and community support groups like 12-steps can be incorporated into an Intensive outpatient program.

 

General outpatient program:  GOP (General outpatient program) is a step-down level of treatment form IOP.  It provides support and structure as individuals gain more confidence in sobriety.  More community based programs can be utilized as people progress on the journey of recovery.

 

Community based program: Community based programs are a long-term support for those dedicated to recovery.  This provides continued guidance and support on a flexible, long-term benefit for lower or no cost. Community programs can also provide an environment for recovering individuals to give back and help support others in their recovery journey.

Contact Us
Illuminate Billing Advocates

720 North 530 East

Orem, UT 84057

T: 801-990-1777
F: 888-855-2850

 

contact@illuminatebilling.com

© 2015 Illuminate Billing Advocates