A Division of A&S Financial Services, Inc.
A Division of A&S Financial Services, Inc.
What is Utilization Management
Inflation and Utilization Management
Components of the Hospital Case Management Program
Tertiary Level Physician Consultants
Consulting Physician Reimbursement Policy
Outpatient Surgery and Diagnostic Procedures Review
Catastrophic Case Management Program
The most costly medical procedures under any healthcare plan are those involving inpatient surgery, hospitalization, outpatient diagnostic, and invasive outpatient procedures. ASMED Health Partnership's services are designed to reduce costs in those areas where you can achieve the largest positive impact on the cost of healthcare for your employees and assure the quality of care to the patient.
ASMED Health Partnership is a national managed health care company helping employers and plan administrators control group medical plan cost. ASMED Health Partnership will reduce your costs by applying effective medical management and cost containment techniques to your plan.
The following pages detail the advantages of the ASMED Health Partnership Second Opinion and Hospital Case Management Program and are presented for your review and consideration.
We welcome your interest and invite you to visit our offices to see first hand the professional manner in which ASMED Health Partnership can assist you in controlling health care expenditures without sacrificing current benefits or patient needs and assuring the quality of patient care.
The ASMED Health Partnership and its affiliated organizations have provided managed care programs since 1983. We have expanded and adapted our services to the changing healthcare environment.
ASMED Health Partnership is an independent, national corporation, therefore, makes all treatment decisions based upon necessity, quality of care to be received, and cost effectiveness.
All medical decisions relating to hospital admissions, lengths of stay and second opinions are performed only by trained medical staff. The medical staff is supported by professionals from employee benefits, the healthcare industry, and information systems.
ASMED Health Partnership exists to provide its clients and their employees the best medical care setting appropriate for the disease, illness or surgery of the patient. The effectiveness of any medical management program relies on how employees understand and use the available services. Since most medical plans now require employees to pay a portion of their hospital and surgical costs, they need to understand the financial benefits of using the program.
Our focus is constantly on the patient and the level of care provided to them. We are as concerned with under utilization and inadequate medical treatment as we are with over-utilization and excessive medical care. In addition to the high professional standards required of our medical staff, we also require that patients who call be treated with respect and dignity accorded to a person in our own family.
Our staff also realizes the trust placed in ASMED Health Partnership to handle your employee's needs during the distressing time of an illness. Therefore, all telephone calls are answered promptly, information requested by telephone, fax, or mail is answered as quickly as possible, and messages are returned quickly and personally at all times.
Our goal is to become an indispensable part of your benefit plan serving both you and your employees.
Utilization Management is comprised of several areas, including second opinion plans, hospital review and prolonged rehabilitation. Utilization Management can be implemented with little change to existing levels of benefits. Some change in eligibility of benefits is used to encourage employees to seek out appropriate treatment in a more cost effective setting.
The basis of sound Utilization Management is to secure appropriate medical treatment for the patient. Trained medical staff assist the attending physician in reviewing the alternatives for the patient, especially when the patient needs acute care or prolonged medical attention.
ASMED Health Partnership is dedicated to reviewing utilization in the areas of inpatient surgery, hospitalization, outpatient diagnostic, and outpatient invasive procedures.
Utilization Management also treats each employee as an individual, recognizing the physical and emotional requirements for treatment. Since medicine is both an art and a science, there can be significant treatment variations with the same result achieved, specifically, the restoration of health to the patient.
The advancement of medical and surgical technique is reducing the average length of a hospital stay. This same advancement is also increasing the cost of each encounter. Therefore, the reduction of even one unnecessary bed day per inpatient stay will significantly alter the total dollars spent by an employer. This reduction can be so significant as to allow the employer to increase benefits or add new coverages, such as dental, pension or disability benefits.
The advantages to the employer and employee are that health plan dollars are saved, which reflects a lower cost to both parties.
Employees and their dependents must become informed buyers in securing healthcare. No employer would consider allowing an employee access to corporate funds without safeguards; yet many employers allow these same employees complete freedom to secure thousands of dollars of expensive medical treatment reimbursed by the employer with no similar safeguards.
The advantages of reduced cost to the employer and the employee far outweigh the additional step required of the employee. Selecting the correct Utilization Management firm to assist the employee is crucial in sound health benefit planning. ASMED Health Partnership exhibits all the criteria needed for effective utilization control, including:
The effectiveness of a healthcare cost management program relies on how employees understand and use the services available. Since most medical plans now require employees to pay a portion of their hospital and surgical costs, they need to understand the financial benefits of using the program. To ensure that your participants understand ASMED Health Partnership's services and the benefits they will receive, ASMED Health Partnership provides your employees with brochures explaining the program to them and how to access the services.
ASMED Health Partnership also provides ongoing information to enhance your employee communications concerning our services and other factors that influence plan costs.
The following is a partial list of correspondence sent to the patient and the physician as required by the patient's particular illness:
As you can see from the extensive list of documents above, all aspects of the ASMED Health Partnership Second Opinion and Hospital Case Management Program are documented in writing to the patient, the primary physician, the consulting physician, the hospital, and the claims payor as events are taking place.
Further, at the close of each case, ASMED Health Partnership sends a patient survey questionnaire to the patient so our services can be evaluated by those utilizing them on a constant, updated basis.
ASMED Health Partnership has participant brochures and stickers detailing the program and the format used to access Second Opinions and Hospital Case Management. These brochures are included in our monthly fee. Customized brochures may be used by your organization so long as ASMED Health Partnership approves all final copy before printing and distribution to participants.
ASMED Health Partnership will work with you to ensure your employees have all the information necessary to use your Utilization Management programs effectively. We will consult with you periodically to confirm that all your employee communication needs are satisfied.
ASMED Health Partnership's level of systems sophistication results in minimal lead time for new clients.
Our systems philosophy is to free the Case Coordinators and the physicians in our office from the burden of administrative paperwork thus allowing them to concentrate on the medical aspects of each case in an individualized manner. The highly unique systems were developed for ASMED Health Partnership by an in-house staff and completely customized for a medically driven Utilization Management program. The systems are state-of-the-art hardware, and can be upgraded to provide for infinite capacity without any change to the system software.
ASMED Health Partnership's systems sophistication results in the ability to customize any reporting required by our clients without additional costs. Too often, automated systems require the user/client to utilize "canned reports" and any changes require time and money. Our systems can be modified as needed by the client at no additional fee. Further, the system can interface with the claims payor streamlining the claims payment processing and resulting in a shorter turn around in claims payment.
ASMED Health Partnership's systems also contain multiple levels of security and both systems and data files are backed up and maintained off site.
An important feature of an Utilization Management program is the ability to communicate with your plan participants. ASMED Health Partnership has established a telephone system which includes the following features:
The following is a partial list of the reports available as required by the client:
The ASMED Health Partnership Second Opinion and Hospital Case Management Program includes the following services:
ASMED Health Partnership maintains a referral panel of over 20,000 board certified physicians throughout the United States to whom we refer our participants for second opinion consultations. It is the policy of ASMED Health Partnership that a covered participant must utilize one of our consultants to obtain their second opinion.
The consultant physicians are selected on the basis of the following criteria:
In addition, the consultant must exhibit the concern and inquisitive nature of a true professional seeking the best care for their client. ASMED Health Partnership maintains a subspecialty list for these physicians wherever possible in order to provide the most knowledgeable consultant possible for the benefit of the client.
In some unusual instances where ASMED Health Partnership questions the validity of medical data being given or the treatment plan, we will request a local consultant to go and review the members' chart on site. Because of ASMED Health Partnership's vast provider network, this is not difficult to accomplish. Please note that these instances are rare and that the telephone is an effective way of communicating in the hands of our trained medical staff.
The ASMED Health Partnership Medical Director is constantly reviewing the criteria for new physician applicants in order to maintain the standards expected by our clients.
Tertiary level care is defined as that surgery which is difficult or unusual and, consequently, can be more costly. Such procedures may include, but are not limited to:
ASMED Health Partnership's Medical Advisory Committee has developed a list of physicians and facilities throughout the United States that are known experts in various types of tertiary level medical procedures. These physicians are known for providing tertiary level procedures on a frequent basis with consistent and positive results.
The advantage of this service to the patient is the review of their case by some of the most qualified physicians in the United States, many of whom are nationally recognized in their field. The plan sponsor benefits from the fact that expensive surgery is performed when necessary and the recovery process is reviewed by recognized experts.
ASMED Health Partnership reimburses its consulting physicians directly on a fee-for-service basis and charges the client/group claims department the amount billed by the physicians for the consultation. ASMED Health Partnership prefers to pay its consulting physicians directly because the physicians know they are going to be paid by ASMED Health Partnership within a fixed time period and because we are able to reduce the cost of the second opinion consultation through our extensive referral network.
Outpatient services is the second largest, and the fastest growing, expense area in medical utilization with about one out of three surgical procedures, and most diagnostic testing being performed in ambulatory outpatient settings. Though outpatient services can provide dramatic cost reductions when compared to inpatient facility expenditures, it is important to ensure that money is not simply being routed from one facility to another. And, as more and more money is diverted to outpatient from inpatient care, the need to manage these services becomes absolutely essential.
ASMED Health Partnership precertifies outpatient surgical procedures and outpatient diagnostic procedures. All patients call ASMED Health Partnership for precertification of outpatient diagnostic and surgical procedures. As a consequence, ASMED Health Partnership precertifies outpatient surgical procedures and reviews surgical procedures that are conducted in the physicians office. Consequently, we are able to identify the medical necessity of those procedures being performed in the physicians office and suggest alternative measures. Expensive diagnostic procedures that are to be performed such as: Colonoscopy, Gastroscopy, Esophagoscopy, etc. are precertified and authorized only in outpatient settings. MRI's and CAT scans are precertified as procedures that must be performed in laboratory settings outside of an inpatient setting. Outpatient setting means the outpatient surgical department of a hospital or a free standing Outpatient Surgical Center. Laboratory means the laboratory department or Radiology department of a hospital or a free standing facility where the patient is only kept for the duration of the procedure. In our managed care program all diagnostic X-ray and laboratory work that is not conducted in the physicians office may be precertified by ASMED Health Partnership.
ASMED Health Partnership's Outpatient Services Review takes a comprehensive approach to outpatient services that includes:
This approach consists of two components that effectively manage growing outpatient expenses:
The two review components can either be implemented together or separately, depending on your needs and utilization experience. This modular approach allows you to tailor the review process, creating a program to fit your specific needs.
ASMED Health Partnership allows the client to further refine the outpatient diagnostic and surgical review process by establishing a predetermined dollar amount that would trigger the review process.
A full third of all elective surgeries can be performed with equal effectiveness in an ambulatory surgical setting. These alternate settings offer significant cost reductions from the average two-day inpatient stay for identical procedures.
Any request for an elective surgical procedure is phoned to ASMED Health Partnership by the attending physician. ASMED Health Partnership's staff physicians determine medical necessity and whether a less intensive outpatient setting, such as a physician's office, outpatient surgery center or outpatient department of a hospital, is appropriate based on the clinical data provided.
ASMED Health Partnership realizes that only physicians can make these kind of qualitative decisions, so every review and all authorizations are performed by staff physicians.
Outpatient Diagnostic Review evaluates proposed diagnostic testing procedures for medical necessity, diagnostic alternatives and setting. As with elective surgical procedures, all requests for diagnostic testing, as qualified by the client's specified parameters, are submitted to ASMED Health Partnership for review of medical necessity, diagnostic alternatives and setting. Staff physicians review the requests along with patient clinical data, and authorize the most cost-effective and medically appropriate setting.
Catastrophic cases involve prolonged hospital stays and/or rehabilitation. Examples of catastrophic cases would include:
When such a situation arises, ASMED Health Partnership immediately notifies the client and claims administrator of any hospitalization which will exceed a predetermined amount. The patient is monitored daily to determine that appropriate medical treatment is provided. ASMED Health Partnership has a national Medical Advisory Committee which is available to assist in identifying appropriate facilities and specialists throughout the United States for the care of catastrophic illnesses.
ASMED Health Partnership will monitor and review the following with regard to the treatment received by the patient:
Further, ASMED Health Partnership will work with all employer directed rehabilitation services.
Please feel free to E-mail us your comments and suggestions to:
jvalor@asfin.com
1996
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