utilization management

Utilization Management (UM) is part of the concept of "managing care" and is one of several functions delegated to CNC. Utilization reviews provide valuable information regarding the utilization patterns of our network providers as it relates to the costs of health care. Keeping network utilization patterns within the range of acceptance is not only a network management responsibility; but since it helps to control costs, it can be a significant factor in determining future reimbursement from contracted payors for chiropractic services.

CNC has chosen to fulfill its utilization management responsibility retrospectively. Our Provider Utilization Management program allows our providers an opportunity to establish utilization patterns based upon their own clinical judgments and compares their utilization patterns only to the practice patterns of their peers in the CNC network. This means that our range of acceptance for utilization patterns is based solely on the collective practice utilization patterns of ALL network providers.

Payors also track physician utilization patterns and CNC is required to meet annually with the Medical Directors and/or QA Committees of our contracted payors to compare the results of the CNC Provider Utilization Management program with the results of the payor utilization reviews.

Our UM program is designed to help our providers be aware of and understand utilization management, to provide an opportunity for our network providers to see how their own utilization patterns compare to their peers, to have a clear understanding of how such information is viewed by the payor and to offer education and assistance to those providers whose utilization patterns place them at risk.

Our utilization management review is conducted annually and once our review is complete, CNC provides this annual utilization report to each network provider. This report compares each CNC provider to his/her colleagues in the CNC network.