Care Management
IFMC’s Care Management services are built around the concept of providing the right health management services at the right time and in the right combination. We provide customized managed care programs to self-insured employers, insurance carriers, health and welfare trusts, third-party administrators, municipalities and preferred provider organizations.
A full range of flexible services enables our company to address all aspects of an organization’s care management needs while working to empower individuals to make the best choices about their care. These services include:
- Utilization Management/Review
- Pre-certification
- Concurrent review
- Discharge planning
- Retrospective review
- Drug Prior Authorization
- Workers’ Compensation Review Disability Management
- Case Management/Review
- Chronic Care Management
- Disease Management
- Maternity Management
- Risk Stratification Software
Utilization Management Programs
Within our Utilization Management programs, our approach facilitates medically appropriate and necessary health care services. Our nurse reviewers apply proprietary screening criteria to each case, evaluating medical necessity and treatment setting. If criteria are not met, cases are referred to one of our more than 280 provider consultants for a determination of medical necessity.
Case Management and Chronic Care Management
Our highly qualified nurse care coordinators work to identify catastrophic and chronic cases to establish individualized care plans to facilitate health improvement. These individualized care plans are developed in collaboration with physicians to promote the best course of medically appropriate care. Program results demonstrate reduced health plan costs and health improvements for program participants.
Disease Management
Our Disease Management program identifies individuals with specific conditions and analyzes their current health status through risk stratification of claims data and clinical assessments. The frequency of contact is based on these factors for stratification within the program.
Maternity Management
Maternity Management incorporates risk assessment, medical treatment coordination and patient education into a single program. Designed to help pregnant women and their families improve maternal and newborn health, the program also provides health plan savings through improved pregnancy and postpartum management.
Integrated Services and Demonstrated Value
Our proprietary patient-centric information system supports integrated and progressive care coordination throughout our Care Management services offered. Integrated services in this information system include:
- Network providers channeling
- Real-time data exchange with third party administrators
- Implementation of 40 different transmission formats – including HIPAA ANSI 278
- Medical records, faxes, and correspondence electronically attached to member record
- Client savings and activity reports
Utilization Management program reports document utilization, health plan savings, provider activity and medical trends with comparison to national normative information. Care Management programs value is demonstrated through actionable report packages documenting outcomes and savings. All reports are specific to the individual health plan or client. Our standard report package includes analysis of program to market trends, recommendations regarding plan design/member education and comparison to book-of-business and national normative data.
Quality Oversight for Care Management
Our Quality Management department has oversight for the following areas:
- Continuous auditing of nurse, provider and call center actions
- Evaluation of complaints
- Oversight for criteria, policies and procedures
- Training and continuing education for staff and provider consultants
- Review of patient safety and quality indicators
- Elimination of exposure to potential compliance and legal challenges
- Distribution and evaluation of member satisfaction surveys
- Oversight for continuous improvement projects
To help ensure our services conform to best practices in the industry, several Care Management programs, including Utilization, Case and Disease Management, are accredited by URAC (also known as the American Accreditation HealthCare Commission) through IFMC subsidiary, ENCOMPASS. Additionally, ENCOMPASS is licensed or certified to provide Utilization Management services in all 50 states. Program capabilities include compliance with DoL (Department of Labor) regulations for ERISA and group plans, carrier customization for compliance with state insurance regulations, and adherence with HIPAA confidentiality and security regulations.
For more information about IFMC’s Care Management Services, contact us at information@ifmc.org or visit www.ENCOMPASSonline.com.