UMass Medical School’s Center for Health Policy and Research evaluates a number of services and providers on behalf of MassHealth, the state Medicaid program. This utilization management review is required by federal and state regulations to ensure that covered services and treatments are medically necessary, appropriate, and cost-effective.
One aspect of the utilization management program focuses on acute and chronic care, as well as rehabilitation hospital services. The review process includes admission and transfer requests, which are evaluated as they are received, as well as periodic post-treatment analysis to evaluate the quality of care and identify areas for program improvement.
Another aspect of the utilization management program focuses on individual providers to identify uncustomary treatment or billing patterns and to investigate consumer complaints. Once a problem area is identified, a peer review team can work with the provider to correct the issue or, if necessary, take disciplinary action.
Provider review categories include but are not limited to:
- Durable medical equipment suppliers
- Independent laboratories
- Oxygen therapy suppliers
- Orthotics and prosthetics suppliers
- Home health agencies
- Imaging services (including MRIs and CAT scans)
- Personal care attendant services
- Occupational, speech, and physical therapy services
- Vision care services