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Incentives statement

Utilization management decision-making

Aetna Better Health® of Illinois does not reward practitioners, providers or employees who perform utilization reviews, including those of the delegated entities for issuing denials of coverage or care. Utilization management (UM) decision-making is based on:

 

  • Appropriateness of care

  • Service 

  • Existence of coverage 

Financial incentives for UM decision makers do not encourage decisions that result in underutilization. Utilization denials are based on the lack of medical necessity or a lack of a covered benefit.

Utilization and claims management systems

Aetna Better Health of Illinois 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 health care is provided to the members. 

Utilization of health care

Aetna Better Health of Illinois has implemented the following measures to ensure appropriate utilization of health care:

 

  • A process that monitors for both underutilization and overutilization of services and, when either is identified, signals us to intervene

  • A system in place that supports the analysis of utilization statistics, the identification of potential quality-of-care issues, the implementation of intervention plans, and the evaluation of the effectiveness of the actions taken

  • A process to support continuity of care across the health care continuum