Preauthorization & Utilization ManagementOur Preauthorization & Utilization Management program provides the foundation for ICM's ability to identify, manage and mitigate clinical episodes within the Self Funded programs we manage. Developed in 1993, this program enables us to ascertain the medical necessity of the services a patient may receive, ensure that the treatment is the most appropriate and cost effective, and most importantly, allow our team to identify high risk and high cost patients early on. Cost SavingsThrough our Preauthorization & Utilization Management program, we are able to provide significant savings by promoting the following interventions:
Program DescriptionOur standard Utilization Review services include the following core deliverables:
How it works: Whenever a patient needs a high cost service, the provider calls ICM. Our Preauthorization Staff then enters the patient's demographics, and verifies that the procedure requires preauthorization according to the customizable parameters set by our client. If the procedure requires preauthorization, the Preauthorization Specialist enters the medical information, verifies that PPO providers are being utilized, and, if possible, authorizes the procedure over the phone. If the procedure is more complex, the Preauthorization Specialist will request clinical notes to go to a Utilization Management RN. Our Utilization Management Nurses use nationally published criteria to determine if the procedure is medically necessary and appropriate based on the information provided. If the procedure is questionable or complex, the information is then forwarded to the Medical Director for a final determination. Additionally, hospitalized patients are concurrently reviewed via telephone throughout their stay. On-site concurrent review may be done in cases where significantly complex medical care is occurring and complex discharge planning needs are identified. With an average turn around time of 3.5 hours, our team of trained specialists and certified nurses is able to quickly and effectively make these determinations, without hindering the care of the patient. Compared to the Department of Labor regulation requiring a determination in 15 days, Innovative Care Management stands out for our speed and efficiency. We are extremely well known and respected by Medical Providers and Hospitals as an efficient, friendly, and professional organization; this respect promotes a collaborative, rather than confrontational, oversight of our mutual members' care. The Preauthorization & Utilization Management TeamAt Innovative Care Management, we pride ourselves on superior customer service, efficiency, quick turn-around time, and accuracy in our determinations; none of this could be done without the two departments of this program. The Utilization Management Department consists of 9 RNs, all with CPUR certification, including a supervisor of the department to oversee the process. Also, the 8 members of our Precertification department undergo extensive training in customer service, medical terminology, and our proprietary database. Additionally, the department supervisor reviews all pre-authorizations, every day, to assure that the highest care and attention are given throughout the process. Case ManagementWhen it comes to healthcare management, it's important to keep in mind that 20% of your enrollees account for 80% of your overall costs. Innovative Care Management's Case Management Program was designed in 1990 specifically to mitigate the financial burden of these high cost patients, while at the same time maintaining timely and appropriate care for seriously ill patients. Through this program, our Nurse Case Managers are able to reduce costs, help the patient receive the best possible care, and maintain a personal and caring approach all at the same time. Cost SavingsThrough focused and attentive management, our Nurse Case Managers strive to ensure that our patients receive the highest quality services, which in the long run prove to be the most cost effective as well. As an example, a patient with terminal cancer who would have otherwise been hospitalized may alternatively receive home health or hospice services in the comfort of his/her own home. At the same time, the employer is not paying for an expensive and unnecessary hospital stay. The following tools and strategies are frequently utilized in our Case Management oversight, leading to significant cost savings for our members and plans alike.
Program DescriptionPatients are first identified by our Preauthorization and Utilization Management departments. If a patient looks to have a potentially high risk situation, the Case Management department is immediately notified. Sometimes, the TPA or the Employer may notify us of potentially high risk patients that they have identified through other means. At this point, a dedicated and highly trained Case Manager is assigned to the patient, with primary responsibility in monitoring patient care and status. A variety of illnesses and complications are covered under ICM's Case Management program, including:
Once a patient is actively case managed, the Nurse Case Manager works closely with the patient, along with the patient's family, providers, and benefit plan to ensure that the patient receives appropriate care and takes preventative measures to avoid higher cost services. Through the use of the following proactive measures, we are able to simultaneously promote a high standard of care and significant cost savings to the member and plan.
The Case Management TeamAt Innovative Care Management, we hire the most experienced employees to serve our patients and clients. Our Case Management team of RNs (2 of whom have RNC certification in maternal, and newborn nursing, 2 more of whom are credentialed in Disease Management, and 80% of whom have CCM certification) compose approximately 40% of our company. This high percentage of professionals speaks to our commitment to provide the finest services to at risk patients. Additionally, there are 3 Case Management Assistants, with a minimum of 6 months experience in our Preauthorization Department, who are trained to handle the specific needs of our Case Managers. Healthy Mother BabyGiving birth to a baby can be one of life's most exciting experiences. However, this experience also has the potential to become a Self Funded plan's largest single cost: the birth of a premature infant. With this in mind, Innovative Care Management developed its Healthy Mother Baby Program in 1992 to promote a healthy and active attitude among pregnant enrollees. With a combination of personal contact from a highly-trained nurse and educational support materials, our Healthy Mother Baby Program is able to encourage expectant mothers to take the necessary steps to promote the likelihood of delivering a healthy baby. Cost SavingsAt a cost frequently in excess of $300,000 per occurrence, the birth of a premature infant is a serious consideration for Self Funded plans and Stop Loss carriers alike. With the Healthy Mother Baby Program, a proactive option is available to minimize this risk, while at the same time providing an extremely useful and appreciated resource for members. Compared to the CDC national average statistics on Premature Deliveries, Innovative Care Management's HMB program stands out in its ability to reduce the financial risk to our clients. Program DescriptionPotential participants for this program are identified through a variety of sources: communication pieces promoting the program, maternity-related claims received by the claims administrator, or sometimes through information taken by our Preauthorization Staff. If the patient is between 12 and 28 weeks of pregnancy, the expectant mother is contacted by one of our Perinatal Nurse Case Managers, given some information regarding the program, and asked if she would like to enroll. Once enrolled, expectant mothers are monitored during their pregnancy and after delivery to ensure that they and their child receive the services they need for a successful outcome. While our focus is on educating the expectant mother, we may also coordinate services with the patient's physician. Enrollment in the program entitles the mother to receive a number of services and materials, including:
Many of our plans provide incentives for the mother to participate in the program, which has been found to be a most effective tool in boosting enrollment. Typically, a gift certificate is mailed to the mother at the end of her pregnancy, which often goes toward the purchase of a car seat or other necessary item for the newborn. Alternative incentives include giving a savings bond in the child's name and/or paying for the childbirth class expenses. Innovative Care Management typically administrates whatever incentive the employer chooses, and the employer is subsequently billed for the additional cost of these incentives. The Healthy Mother Baby TeamOur Healthy Mother Baby Program aims to ensure that expectant mothers have the best information and advice available, and to that end, Innovative Care Management currently has 2 RNCs, certified registered nurses specializing in maternal and newborn health, running the program. With the aid of a dedicated Healthy Mother Baby Assistant, our team is able to provide efficient, quality care to our maternity patients. Disease ManagementThe Disease Management Program is designed to provide your enrollees and you with supplementary Cost SavingsThe most recent statistics indicate that the average person spends $6,280 on healthcare per year. Those with chronic diseases spend 7 times this amount every year, which is nearly $44,000 per person per year. More effective self management skills significantly impact these costs. The ICM Nurse provides comprehensive individualized education and instruction to employees with any of the following conditions: asthma, heart disease, heart failure, diabetes, and/or emphysema. The goal is to promote enhanced employee self care. Medical Director ServicesIn a field such as medical management, it is very important to constantly ensure that our members' care is never compromised. It is our role to assure that the care proposed is appropriate, timely, and covered by the plan we are working for. It is precisely for this purpose that Innovative Care Management includes Medical Director Services as an adjunct to all of our programs. ICM's Medical Director is a board certified physician who can provide objective determinations of medical necessity, clinical oversight, and frequently assists in the development of our clients' plan wording and policies. Program DescriptionThe Medical Director is an essential component to all of Innovative Care Management's services, and plays in active part in our decision making process. In the interest of providing only the best in medical management, the Medical Director provides such services as:
Pharmacy ReviewNot all high-risk and high-cost patients have costly procedures that would typically alert us to their need for Case Management oversight. Our Pharmacy Review program was designed as an alternate method of detecting patients with chronic conditions that would benefit from our Case Management and/or Disease Management programs. Additionally, the program provides a method of:
Cost SavingsOur ability to detect patients with chronic conditions through clinical and pharmaceutical identification allows us to encourage the patient in caring for their condition properly, with the end result being fewer hospitalizations and high cost treatments. Our approach is to ensure that appropriate preventative measures are being taken, rather than far more expensive reactive measures. Additionally, our ability to detect misuse of certain drugs and coordinate physician interaction allows us to identify such cases and control the problems they cause. For instance, if a patient is receiving multiple prescriptions from a variety of physicians that may overlap or even conflict with each other, we contact the prescribing physicians and promote that the patient receives the necessary medications from only one prescribing physician. Or, if a patient has a high usage of narcotics, we have the ability to do a tablet count and determine if a better alternative exists for the patient, at the same time reducing the number of prescriptions the patient is receiving. Program DescriptionEvery month, we receive a report from the client’s Pharmacy Benefit Manager (PBM), and from the data, we identify the patients based on a variety of parameters. Based on this data, we sort which patients are potentially high risk patients, get claims data from the TPA, and a complete list of prescription information from the PBM. From this data, we are able to determine which patients would benefit from Case Management or Disease Management, and are also able to determine if there are any red flags regarding drug usage, eligibility, or incorrect billing. Implementation of this program requires extensive collaboration with the employer's pharmacy benefit manager (PBM). Currently, ICM has established relationships with multiple PBMs where we can easily retrieve data from existing report databases at no extra cost. We are also able to work with new PBMs to establish a similar relationship. The fee for this program covers the compilation and analysis of reports from the vendor. Patients identified through this mechanism are referred to the Case Management or Disease Management programs to facilitate the appropriate treatment plan and manage costs. 24x7 Nurse LineImmediate professional assistance and advice for medical questions and concerns available 24 hours a day, 7 days a week. Cost savingsDesigned to assist enrollees in making appropriate decisions regarding seeking emergency care and proactively identify enrollees who may need case management services. Program description
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