James Dunham BS, MHA, MBAPresident
Director, Revenue Cycle
Scott Farnsworth BS, MHA, MSVice President of Operations
Dale Pinkerton RN, BSNVice President,
Nursing Consulting Services
John Dunham RN, BS, MHAExecutive Director,
Care Coordination/Clinical Integration
Lyndsay Farnsworth RN, BSNDirector, Nursing Consulting Services
Michele MannDirector, Business Development
Jenny Ghost BearOpening Prayer and Song
3314 Lynnwood Ave
Rapid City, SD 57701
Utilization Review Services
Utilization Management has evolved from the Utilization Review process into a comprehensive system not only to evaluate the appropriateness of care using defined severity of illness and intensity of service criteria but to monitor expenses and resources as well as a driver for quality assurance and improvement.
Medical necessity should always be the determining factor when it comes to the appropriateness of medical treatment, with payer constraints and resource allocation ultimately being factored into the equation.
With the advent of the Patient Protection and Affordable Care Act (ACA or Obamacare), government regulators and insurance companies will be attempting to rein in healthcare costs. The Utilization Review process will need to stay on top of regulatory changes for future relevance. Managing resources and ensuring that care is rendered in appropriate settings will continue to be important as well as expanding the focus into preventative care, disease management programs and quality assurance improvement.
North American Tribal Organization will provide education and review of processes for your organization’s Utilization Review Plan to ensure compliance with the provider's Conditions of Participation contract with Medicare and Medicaid services. Along with Case Management, appropriate Utilization Review ensures appropriate care is provided, cost overrun is avoided, and reimbursement is optimized.