Health & Wellness Programs

Inpatient Utilization Management Services

This service evaluates inpatient admissions and acute mental health and substance services using nationally recognized guidelines and criteria. This includes review of the appropriateness of treatment plans, length of stay and discharge plans on concurrent and/or retrospective basis.

Maternity Obstetrics Management (MOM)

Expectant mothers are assigned to a nurse specializing in maternity care. This includes risk assessments each trimester, education and information specific to each member’s needs.

Pathology and Diagnostic Review

A full review and report on all biopsies, colonoscopies, MRI, CAT and PET scans to identify potential case management cases early and before costly treatment begins.

Outpatient Review Utilization Management*

This service reviews and evaluates the use of outpatient health care services and procedures using Milliman guidelines and criteria. Any procedure that may require an overnight stay (change in calendar day) will need to be reviewed for the medical necessity and intensity of service of that admission.

Out Patient Behavioral Health Case Management

Provides precertification and review of mental health and substance review cases for outpatient services, step-down, partial day and short/long-term rehabilitation programs.

Pre-Determinations/Medical Necessity Reviews

Medical necessity reviews (MNR) are performed to assist TPAs with claims determinations and adjudication. MNRs may require review by a physician of the same specialty for complex and costly treatments plans to guide medical necessity determinations. Medical necessity is substantiated and evidenced using nationally accepted guidelines and compendia based evidence for research of the following:

Case Management
Case management monitors and coordinates care of members with specific diagnoses and/or potentially requiring high-cost or extensive services. Helps patients navigate through the complex maze of healthcare and create more cost effective use of care with good outcomes.

Medical Disclosure/High Cost Claim Projections and Review
This service provides stop-loss carriers/MGUs with in-depth clinical assessments on individual members for use when making underwriting decisions. Reports include treatment or surgical plan with medical and Rx cost projections for the next 12 months.

Chronic Condition Care Management
This service educates, monitors and manages patients with chronic diseases such as diabetes, CHF, COPD, asthma and CAD to prevent unnecessary ER visits, inpatient admissions, re-admissions and escalating costs from non-compliant behaviors.

 

BioMetrics and Disease Management Health Coaching

  • Online health risk assessment (HRA)
  • Optional paper HRA available for additional fee
  • Health history completed by participant
  • Lab test (28 panel)
  • Height/Weight and BMI calculation
  • Medical staff (e.g., nurse, phlebotomist/medical assistant)
  • Supplies/Equipment needed for event
  • Scheduling (800# or online)
  • Pre-event online employee communications
  • Comprehensive and individualized online member reporting
  • Physician review of all lab results and nurse outreach to members with abnormal biometric results to provide guidance and suggested next steps

Nurse 24/7/365

Members can access telephonic healthcare information and nurse triage 24 hours a day, seven days a week. Includes 1,100 topic audio health information library (HIL) and a nurse line.

Call MD 24/7/365

Unlimited access to physicians nationwide for medical advice and non-DEA controlled prescriptions 24/7/365.

Patient Advocacy

The healthcare system is ever changing and confusing. This Patient Advocacy Program assists members and patients with a unique, personalized solution aimed at assisting them in navigating through the complexities of our fragmented system. We recognize clients have different cultures and philosophies and may want to address different areas, so we develop a customizable advocacy program that fits your needs.

In and Out-of-Network Discounts

This service provides repricing or negotiation of in- and out-of-network claims, line-by-line review for inadequate documentation to support claims and review for inappropriate billing; includes defense of balance billing.

Kidney Care and Renal Dialysis Program

Additionally we supply suggested plan language changes to support the ability to carve out renal dialysis treatments from the PPO.

This program can include our kidney care case management program for overall management, education and monitoring, which often times results in delaying the need for full dialysis.