Medical Management
Pre-Authorization and Utilization Management
Pre-authorization (Inpatient and Outpatient Services). During the pre-certification process, members or physicians register future procedures or surgeries with Gateway nursing staff under the direct supervision of our Medical Director. This gives us the opportunity to explore alternatives related to the particular procedure, whether length of stay, location or cost re-negotiation. Furthermore, early knowledge of a procedure allows us to better direct care and to send educational materials that are extremely helpful to the patient and family members. Denials are authorized only by the Medical Director.
Concurrent Inpatient Review. Following each pre-certification, our medical department performs a review to determine that a patient’s treatment is received as outlined by the physician and agreed as medically indicated by our Medical Director. Active monitoring and thorough evaluation of a patient’s length of stay, change in diagnosis, and treatment progress ensures necessary and appropriate healthcare, while avoiding unnecessary expenses when a hospital confinement or a surgical procedure is proposed. Utilization reports can be generated in terms of diagnosis codes, reasons for non-payment, COB savings, providers, individuals/divisions, dollar amounts, etc.
Gateway Health uses the industries’ top Evidenced-Based Care Guidelines to help make Utilization Management decisions.
Following each pre-certification, our medical department performs a review to determine that a patient’s treatment is received as outlined by the physician and agreed as medically indicated by our Medical Director.
Active monitoring and thorough evaluation of a patient’s length of stay, change in diagnosis, and treatment progress ensures necessary and appropriate healthcare, while avoiding unnecessary expenses when a hospital confinement or a surgical procedure is proposed. Utilization reports can be generated in terms of diagnosis codes, reasons for non-payment, COB savings, providers, individuals/divisions, dollar amounts, etc.
Utilization Comparison | Gateway Health vs. Major Competitor |
Admissions / 1,000 Members | 18.7% Fewer Admissions |
Average Length of Stay (ALOS) | 24.4% Decreased ALOS |
Inpatient Days / 1,000 Members | 32.3% Fewer Inpatient Hospital Days |
(Sources – Health Insurer & Gateway Health Client Reports)
URAC
Utilization Review Accreditation Commission/ URAC is a nationally recognized non-profit, quality improvement leader that reviews and audits a broad array of health care service functions and systems. URAC standards promote evidence-based practice, collaborative relationships with providers, consumer education and shared-decision making with consumers. These standards apply to all types of organizations providing services for individuals with chronic illnesses, including health plans, stand-alone disease management organizations and medical management organizations.
Health Utilization Management
10/01/2026
Case Management
This essentially can be divided into two areas: catastrophic case management and episode management. Both are extremely cost effective for our clients. After determining potentially high cost, high utilization cases through in-house analysis of usage data, Gateway’s medically trained team assesses a situation then coordinates, monitors, and evaluates options and services. Quality, cost effective outcomes are achieved by meeting an individual’s health needs. Evidence of cost savings resulting from our case management is demonstrated through our customized reporting.