Cost Containment Services
Medical Case Management
Medical Case Management is defined as the timely coordination of medical care to meet an individual’s healthcare needs and maximize the use of benefit dollars while supporting a quality medical treatment plan. It involves review of the whole picture of the participant’s health and medical status, problems, treatment necessary, treatment being given and alternatives to care. It also includes a review of the cost of services, drugs, equipment, supplies; price negotiation; and long-term cost estimates.
Medical Rehabilitation Consultants provides management of medical treatment plans for individuals who require coordination of catastrophic illness or injury, and for those who need assistance with management of chronic illness or complicated diagnostic or treatment problems. Medical case management services are based on referrals from the benefit plan administrator and cases identified through utilization review and disease management programs.
Injuries and illnesses impact not only the individual, but also the family, friends, employers, and the community. Medical Rehabilitation Consultants provide personal involvement to decrease emotional and physical stress on everyone involved. Medical Rehabilitation Consultants utilizes registered nurses as case managers/nurse consultants to provide timely coordination of medical care to meet an individual’s healthcare needs and maximize the use of benefit dollars while supporting a quality medical treatment plan. Our services involve a review of the whole picture of the individual’s health and medical status, problems/barriers to recovery, treatment being given, treatment necessary, and alternatives to care. It also includes a review of the cost of services, drugs, equipment, supplies, and price negotiation for these as well as work-related issues and long-term cost estimates.
The participant is assigned a Registered Nurse with hospital and medical case management experience. They will work with the participant, physicians, and any other providers who are participating in the case to ensure all parties have the same accurate information about the participant’s needs and care. If there are alternative treatment options, they will present these to the participant and physician and will assist with referrals. Our nurse consultants coordinate medical care to increase the efficiency of benefit utilization. Our early intervention helps identify and maximize the chances for the best outcome for the individual. We provide easy to understand and concise documentation of our assessment, intervention, and recommendations.
The Nurse Consultant will provide the participant with as much information as possible about the medical condition and treatment plan so that the participant and physician can make the best decisions regarding care. The Nurse Consultant will respect the participant’s right to make the decisions for their own health care.
There may be times when recommended treatment is not covered by the benefit plan. The Nurse Consultant will review the request and if this service meets criteria and is medically necessary and appropriate, the Nurse Consultant may present this information to the plan for consideration of payment. The decision to pay for such services is solely the decision of the plan.
If the participant is hospitalized, the Nurse Consultant will work with the hospital staff and physician to ensure the participant is receiving the very best care available at the most appropriate level of care necessary. The Nurse Consultant will participate in discharge planning to be certain any special needs the participant will have at home are accommodated. If the participant is in need of transfer to another facility, the Nurse Consultant will work with their staff to provide a safe and smooth transition.
Emphasis is placed on appropriate medical care, progression of treatment, return to work, education and claim resolution.
Our unique program provides medical management :
- Comprehensive initial assessment
- Physician consultation
- Patient and family assessment
- Patient and family education
- Home needs assessment
- Review of various treatment options
- Review of work-related issues
- Cost containment services
- Follow-up recommendations
- Monthly reporting to your specifications
The benefits of medical case management include:.
Our unique program provides medical cost containment:
- Early Intervention
- Efficient utilization of benefits
- Cost containment
- Appropriate, effective and timely treatment
- Negotiated rates
- Patient encouraged to actively participate in their health care
- Improved medical compliance
- Coordination of care
- Educational resources
The following situations are “red flags” due to their known risks as high-dollar claims based on diagnoses and slow or lack of progress toward recovery and resolution.
All designated claims are reviewed on a case-by-case basis:
- Long-term care needs
- Extended in-patient course
- Equipment/supplies/therapy needs
- In-home service needs
- Poor recovery/complications
- Complicated diagnosis and/or treatment plan
- Delayed diagnosis/no diagnosis
- Changing diagnosis
- Multiple diagnoses/diagnostics
- Multiple medical providers
- Patient dissatisfaction/lack of information
- Bariatric surgery
- Failed treatment
Conditions that initiate immediate medical case management
The following are some example catastrophic injury, illness and disease conditions :
- High-risk pregnancy
- Premature birth
- Major or multiple congenital anomalies
- Circulatory/Cardiovascular disease or failure
- Thermal burns or frostbite (child > 10%, adult > 20%)
- Crush Injuries, amputations
- Multiple trauma
- Respiratory dependency
- Chronic bronchitis or asthma
- Spine injuries
- Brain injuries or trauma
- Unconsciousness – any cause
- Electrical injuries
- Radiation treatment
- AIDS (Acquired Immune Deficiency Syndrome)