Treatments and procedures based on scientific literature

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Reference no: EM133873193

Question

At a previous employer, I wrote the UM (utilization management) criteria for many treatments and procedures based on scientific literature (these were typically newer procedures). We also deferred to Milliman guidelines for a more established standard of care treatment. In these meetings we would review the patient request and denial and determine medical necessity. We didn't win every case, but we didn't lose everyone either. Oftentimes if a procedure was deemed medically necessary then the denial would be reversed, and the treatment would be covered. So, while UM criteria existed, it wasn't always upheld. What did help was the evidence-based guidelines we had in place that if needed, could prove that even though it may be medically necessary it may not be safe. Currently I write evidence-based guidelines as well at a different health care organization and we use these to guide care which can reduce risk. Class, do you think that having these guidelines reduces risks?

Reference no: EM133873193

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