Sunshine Health does not reward practitioners, providers, or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. UM decision making is based only on appropriateness of care, service, and existence of coverage. Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on lack of medical necessity or lack of covered benefit.
Sunshine Health and its delegated health plan partners have utilization and claims management systems in place in order to identify, track, and monitor the care provided and to ensure appropriate healthcare is provided to the members.
Sunshine Health has implemented the following measures to ensure appropriate utilization of health care:
- A process to monitor for under and overutilization of services and take the appropriate intervention when identified.
- A system in place to support the analysis of utilization statistics, identification of potential quality of care issues, implementation of intervention plans and evaluation of the effectiveness of the actions taken.
- A process to support continuity of care across the health care continuum.