Buck Bond Group
Are high-cost health claims keeping you awake at night?

Are high-cost health claims keeping you awake at night?

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Nearly half the medical and pharmacy expenditures for a self-funded plan stem from claims for medical care for high-to-catastrophic illnesses. So, a well-run care management program should always be part of your organization’s cost containment strategy.  

The goal of care management is to ensure members receive quality health care services in a cost-effective manner. Focusing care management services on your sickest plan members can not only improve the patient experience, but it may also reduce duplicate services and minimize low-value or inappropriate services.  

Effective care management programs are designed to ensure that medical interventions meet accepted clinical criteria for coverage under the plan. They also help patients to access the most appropriate level of care, coordinate services, support patients and families, and reduce unnecessary complications and costs.  

It has been widely observed that a good case management process can reduce the length of stays in hospital, diminish prescription errors, reduce duplicate testing, and lower readmission rates.  Unfortunately, many care management programs fall short of these goals.  

Make sure your care management program delivers results  

Care management programs are typically delivered by your organization’s self-funded health plan, TPA or third-party vendor, and include a number of offerings that assist members along the health care continuum. 

While claims, eligibility, and pharmacy audits are common, many employers do not evaluate the delivery of care management programs, their impact on member health, and financial outcomes.  To ensure these patients receive the best possible quality and most cost-effective care, it’s important to conduct  regular care management coordination and oversight audits.   

Care management program audit 

An audit should include a review of processes designed to assess not only the program structure, but also program execution and the audit’s subsequent impact on health and financial outcomes. The goal is to assure program integration, promote early identification of problem areas, evaluate the appropriateness of interventions, and help ensure the program is providing an efficient, well-coordinated, and valuable experience for the member. For employers who have additional care management programs such as disease management and wellness, it’s also important to ensure that coordination within and between programs is working well. 

Program improvements 

A care management audit is an ideal way to evaluate the care management program’s operational strengths and weaknesses and ability to impact health and financial outcomes.  The findings can also help to identify opportunities and inconsistencies that can create financial risk and reduced value unless corrected. Common audit findings include: 

  • Lack of timely identification of candidates
  • Ineffective outreach and follow up
  • Ineffective/ inadequate nursing interventions
  • Poorly executed policies and procedures
  • Inconsistent application of clinical criteria
  • Delays in concurrent reviews and discharge planning
  • Undetected/unmanaged large claimants
  • Little or no integration with other clinical programs such as EAP’s, employee clinics, and wellness programs

 It’s in your hands 

Under an employer-sponsored, self-insured health plan, the employer ultimately pays for any inefficiencies associated with the delivery of care management services. Employers who take the time to ensure a healthy care management process will benefit from positive health and financial outcomes as their employees reach their optimum level of wellness, self-care management, and functional capability.