Program Highlights
~ We provide a team of registered nurses that conduct assessments on complex cases utilizing Milliman Care Guidelines (MCG) to assess the medical appropriateness of inpatient admissions. Outcomes are benchmarked against MCG Health days per 1000 and average length of stay criteria to certify treatments. ~ Continued collaboration throughout the member’s treatment, including ongoing assessments of the interventions related to the plan of care, ensures that all members receive the right care at the right time to achieve the best possible outcomes. This integrated care management approach allows for the automatic trigger of a patient identified as high-risk by the utilization nurse to case management. Peer to peer reviews are conducted by the Medical Director as appropriate. Daily call-outs are made based upon last date credited. ~ Our interdisciplinary Risk Management Team works together to coordinate and communicate all issues surrounding our clients’ high-risk cases. Our fully integrated team approach eases the burden of healthcare expenses for employer groups while ensuring plan members receive optimum care. ~ The Precertification Program also includes the review and assessment of the medical appropriateness of admissions for inpatient, partial hospital, inpatient rehabilitation, residential treatment and subacute care. This review may be a prospective, concurrent or retrospective review.
More appropriate utilization
Better outcomes
Higher engagement
93%
3.3% 7.6% 6.7%
10%
reduction in inpatient length of stay
fewer
readmissions
identified members receive complex case management outreach
3.4% 3.2%
reduction in avoidable admissions
reduction
in medical costs
86%
reduction
reduction in costs for outpatient services
of high cost individuals engaged with case management
in ER utilization
28
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