Utilization Management 101

What is Utilization Management and Why Does it Matter?

While definitions may vary, the purpose and overall need for Utilization Management (UM), also known as Utilization Review (UR), remain the same. This process looks at the medical reason(s) for needing treatment and whether or not the care provided is effective and appropriate for the individual.

Steps always include getting approval for treatment from the patient’s insurance provider. Before treatment can begin, the treatment center’s Utilization Management Clinician will contact the assigned Case Manager from the insurance company to discuss the patient’s medical and treatment history, the estimated length of stay, treatment goals, and treatment plan. From here, several days are usually approved and the patient can begin treatment. Regular reviews are then scheduled to obtain additional time as the individual progresses toward recovery.

By regularly reviewing and monitoring the care being received, UM helps make sure patients receive quality, affordable care and continued support from insurance along their journey to recovery.

The UM Guru of EDCare

Meet Keira Ebersviller, EDCare’s Utilization Management Supervisor. Since 2013, Keira has advocated for patients at all EDCare locations with her compassionate and patient-centered attitude. Keira graduated from the University of Minnesota with a Bachelor’s Degree in Psychology and a minor in Law and Criminal Deviance. She later earned her Master’s degree in Counseling Psychology at the University of St. Thomas and is now a Licensed Professional Counselor. Today Keira has over 10 years of experience in managed behavioral healthcare and direct clinical care. Having worked on both sides of managed care, she is an expert at handling behavioral health insurance issues.

Why EDCare Strives for Quality UM Representation

Eating Disorders are a serious mental illness. In America, it is estimated nearly 20 million women and 10 million men are affected by an eating disorder. While progress has been made, there is still much misunderstanding in the diagnosis and treatment of eating disorders as a mental health issue. This can make getting insurance coverage for the right level of care a confusing and frustrating process. This is why EDCare believes having quality UM representation is an important part of patient advocacy.

At EDCare, Keira acts as a liaison between patients and their insurance providers. Throughout a patient’s treatment, Keira works to build a mutual working relationship with insurance companies and individual case managers. By communicating at each stage of the recovery process, Case Managers gain a deep understanding of the patient’s unique needs, progress in treatment and additional resources that may be helpful. Unfortunately, denial of coverage can happen. When it does, Keira and our treatment team will often request an appeal and present evidence as to why additional time in treatment is needed. By having an open, working relationship with insurance providers our clinical team is able to truly provide individualized care and do what is clinically right for the patient.

Eating disorders and eating disorder treatment is complex. Understanding how utilization review policies and procedures can affect healthcare is an important part of delivering and receiving excellent care. Having worked in both fields, Keira draws upon her unique professional background, to bridge the gap between insurance companies and their understanding of eating disorders as a severe mental health condition. Fighting for our patients and their recovery needs makes Keira an invaluable asset to the EDCare team and you or your loved one’s journey to recovery.

Getting the eating disorder treatment you need shouldn’t be complicated. Keira and our entire team are here to advocate for YOU! Let us eliminate the stress of getting insurance coverage so you can focus on recovery – 100%. If you or a loved one is suffering from an eating disorder, call (866) 771-0861 today or submit a free, confidential inquiry form online. Don’t lose hope, help is just a call/click away.