ABSTRACT
An insured’s benefit equals expense and risk exposure to the payor’s bottom line. Therefore, for their organization to represent benefit and attractiveness to a payor, physicians must be able to manage utilization and also show their management plan on paper. To start an organization and make sense of their provider service agreements, physicians must have at least the framework of a utilization management policy on paper. The medical records documentation guidelines for their network organization should probably mirror the National Committee for Quality Assurance standards. While electronic medical records systems generally force many of these points, there may be physicians who have not yet adopted an Electronic Medical Records system or who have adopted one that does not quite do the job necessary. Physicians will be well on their way to establishing the network as one who is serious about managing quality and utilization while rendering appropriate patient care.
