Products & Services
Care Management Services reduce health care costs by managing the care of members at greatest risk for high dollar claims.
How it Works:
- Starts as a collaborative process to assess, plan implement, coordinate, monitor and evaluate options / services
- Identification managed through UM, Referral, Predictive Modeling, Disease Management
- Targets high-risk, high-cost, complex needs
- Assures RIGHT care at RIGHT setting
- Long term intensive coordinated approach
- Patient / provider advocacy
- Patient education and support
- Coordination of services
- Identification of alternative funding
- Early notification of potential high dollar claims
- Coordination with existing networks / centers of excellence
- Services include working with:
- Home health
- SNF
- Hospice
- DME
- Infusions
- Injectable drugs
- Pharmaceuticals
- Rehab
- Transplants
The Process:
The Results of Case Management Program Services include:
- Reduction in Utilization
- Decrease in admissions / re-admissions to the hospital and ER
- Timely transitions to lower levels of care
- Initiation and discontinuation of services based on member readiness and response to treatment
- Fewer complications due to increase compliance and self-care competencies
- Lowered variance of treatment plan to evidenced-based medicine or national guidelines
- Negotiated Savings
- Coordination with other vendors and programs
- Alignment of benefits
- Assure that services are medically necessary, high quality and provided in the appropriate, cost effective setting.
- Identification of shock-loss cases that will meet reinsurance thresholds
- Promotion of timely discharge and transition to lower levels of appropriate care
- Identification of early referrals for case and disease management
- Promotion of higher member satisfaction rates.
