URAC Accreditation

CASE MANAGEMENT:

Case management services are one of the fastest-growing practice areas in health care today. Health care organizations use case management to better meet patients’ needs and improve their treatment outcomes by coordinating the full continuum of care. URAC is the only accreditation organization offering standards that specifically address the rapidly evolving field of case management.

URAC has accredited hundreds of organizations that provide all types of case management services, in both health and workers’ compensation settings — helping ensure that their case management offerings are of the highest quality. URAC designed the standards to fit organizations that provide telephonic or onsite case management services in conjunction with a privately or publicly funded benefits program across settings and specialties. Accreditation or certification is available depending on the type of organization and services being offered.

The URAC standards cover several critical operational categories for any quality case management program including:

• Staff Structure and Organization
• Staff Management and Development
• Information Management
• Quality Improvement
• Oversight of Delegated Functions
• Organizational Ethics
• Complaints

DISEASE MANAGEMENT:

Focusing the right resources at the right time to achieve the best outcomes for patients with chronic disease is more than just good medicine. It’s good business. That’s why disease management (DM) has become such a critical component of today’s health plans. How can you be certain that your DM program is achieving its full potential? URAC’s Disease Management Accreditation and Certification programs provide a comprehensive benchmarking system.

Built on the standards developed with a committee of disease management experts, URAC’s program equips disease management organizations with the tools needed to promote quality and better assess and respond to the needs of health plan members. The URAC DM standards promote:

• Evidence-based practice
• Collaborative relationships with providers
• Consumer education
• Shared-decision making with consumers

URAC’s DM standards are not disease specific. They apply to all types of organizations providing services for individuals with chronic illnesses — including health plans, stand-alone DM organizations and medical management organizations. And because URAC’s accreditation program is based on structure and process, we can accredit any DM program. Additionally, companies that are vendors to disease management organizations and programs are eligible for DM Certification.

HEALTH UTILIZATION MANAGEMENT:

Most medical care paid for by private or public health insurance undergoes some form of administrative review to determine the appropriateness of proposed medical care. That means almost every American enrolled in a private or government funded health benefit plan is affected by how this type of review is administered. In 1990, URAC developed the first Health Utilization Management (UM) Review Standards to ensure that organizations conducting utilization review followed a process that was clinically sound and respected patients’ and providers’ rights while giving payors reasonable guidelines to follow.

Today, URAC is the undisputed leader in Utilization Management Accreditation and Certification. Since creating the first standards that set the bar for health utilization review, URAC has continued to create and revise the standards that have transformed the industry. URAC’s current Health Utilization Management and Workers Compensation Utilization Management standards build on the Core Accreditation Standards, and:

• Establish consistency and maintain the highest confidentiality in UM processes
• Serve as the basis for many states’ laws and regulations and are the most widely recognized UM standards at the state and federal level
• Are applicable to stand-alone UM organizations and UM functions within health benefits programs such as indemnity insurance, health maintenance organizations (HMOs), preferred provider organizations (PPOs), and the newer Consumer-Directed Health Care plans
• Can be adopted by specialty UM companies, such as behavioral health and CAM
• Are compatible with the 2002 U.S. Department of Labor claims regulations

HEALTH UTILIZATION MANAGEMENT - PUERTO RICO:

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