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Cost Management Programs

 

Utilization management and case management services are available at HealthSmart A group of dedicated nursing professionals provides pre-certification, concurrent review, discharge planning, and case management services for customers wishing to monitor the inpatient, outpatient, or diagnostic utilization of their plan.

Managed care alternatives are provided to our customers by bringing together leading network resources and continually assessing appropriateness of the networks to match the specific needs of employers.

 

Our goal is to provide our customers and prospects with the highest quality network, substantial discount arrangements, flexibility, and medical management control mechanisms.

 

Our Cost Management Programs include:


Utilization Review

 

Utilization review is the opportunity to review a request for medical treatment. It also helps to minimize costs and determine if the recommended treatment is appropriate. The term “utilization review” refers to a retrospective review of treatments or services that have already been administered, and review medical files in comparison with treatment guidelines.


Case Management

 

The Case Manager completes an assessment of available clinical data and performs an information intake with patient, family, physicians, and facilities. A plan of care is developed to satisfy the patient’s care needs from cost effective service providers. The Case Manager assists as a patient advocate during care planning and transition services. Ongoing contact for the patient and family is provided by the Case Management nurse to assist with care and reimbursement coordination and decision. Each Case Manager tracks the status and activity in the system while tracking patient savings to be reported.

 

 

Some of the specialties are:

  • Oncology
  • Neonatal
  • High risk pregnancy
  • Mental nervous
  • Transplant


Pre-Certification

Pre-certification is the pre-approval process for treatments found on your insurance policy’s pre-certification list. Most lists include non-emergency hospitalizations, outpatient surgery, skilled nursing and rehabilitation services, home care services, and some home medical equipment. The review and approval involves determining whether the requested service is medically necessary.

The process begins with the collection of information, including the symptoms, diagnosis, results of any lab tests, and list of required services.


Concurrent Review

Much like pre-certification reviews, concurrent reviews are used for approval of medically necessary treatments or services. However, concurrent reviews happen during active management of a condition, be it inpatient or ongoing outpatient care. The focus of concurrent review is to ensure that the patient is getting the right care in a timely and cost-effective way.

An important part of the concurrent review is the assessment of the patient’s needs after a hospitalization. Because concurrent review is used to decrease the amount of time you spend in the hospital, the first concurrent review often determines a discharge plan.


Disease Management

 

Disease management provides support for members through telephonic assessment, coaching, compliance monitoring, supported by mailing of education material. Members are identified from pre-certification activity and from claims payment activity, including pharmacy data to help them manage their diseases, as effectively as they can, to improve their health and minimize the use of healthcare dollars.


Health eCare

 

Health eCare is a comprehensive yet affordable medical and risk management software tool used to manage your health care costs. Click here to learn more about our Health eCare product.