Utilization Management/Pre-certification

Utilization Review (UR) services assure cost effective care which is medically necessary, and delivered in the most appropriate setting, based on nationally recognized and widely accepted guidelines and criteria.

Procedurally, UR involves the collection, assessment and documentation of supportive clinical information, monitoring and evaluation of admission criteria, continued stay review, discharge planning, and the identification and referral of patients who could potentially benefit from Case Management. Services include:

• Inpatient Care Review (medical/surgical, rehabilitation, and hospice)
• Prospective Admission Review
• Urgent/Emergent Admission Review
• Concurrent Stay Review
• Discharge Planning
• Identification of Patients for Case Management
• Appeal Review of Adverse Utilization Management Decisions
• Medical Director Oversight
• Home Health Care and Home Hospice
• Outpatient Physical, Occupational, and Speech Therapies
• Durable Medical Equipment Purchases
• Certificate of Non-Availability (appropriate use of non-network providers)
• Selected Outpatient Diagnostic and Surgical Procedures
• Infertility Services
• Chiropractic Care
• Skilled and Private Duty Nursing

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Case Management

The objective of large case management is to reduce risk and related costs through coordination of services and resources to respond to an individual’s health care needs. The Case Manager supports the physician’s plan of care in a manner that maximizes treatment received and overall cost effectiveness of that care. Patients involved are those with catastrophic illnesses or injury.
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Fee Negotiation

Involving the identification of claims for care provided by non-network providers, fee negotiation is perhaps the most often overlooked cost containment technique. Performed either prospectively or retrospectively, negotiations directed by skilled negotiators can result in significant savings. Key to the process are identification of eligible claims, active, experience-based negotiation with providers in lieu of a claim audit and timely payment processing.
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Disease Management

Disease Management is a comprehensive, systematic approach to the management of a disease or a condition, spanning the continuum of care from prevention through the ongoing, long-term health maintenance of a patient with a chronic health condition or diagnosis. Disease Management takes the most costly ailments and health conditions and manages them through clinical protocols. It is an effective health tool to sustain the quality of care, while controlling health costs by avoiding exacerbations of disease and frequent hospital admissions

The Spectrum Administrators’ Disease Management program focuses on those patients with chronic illnesses like asthma, congestive heart failure, diabetes, hypertension, as well as, high-risk maternity, disease states which are credited with high dollar cost, high utilization of services and a high incidence of occurrence.

Spectrum provides unique proactive risk management services that fall directly in line with the philosophies of prevention and cost control.
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The 20-80 principle - 20% of plan members relate to 80% of the plan cost. It has been found, further, that 3-5% will incur 50-60% of program expenses. Focus must be placed on this population.
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Early intervention results in reduced cost. Simply identifying patients once their claims have exceeded an established threshold is inherently ineffective and opportunities for significant impact are reduced. A systematic, disease-based approach is most effective. The willingness of patients to comply with prescribed care is critical to the cost control process.

The Spectrum Administrators approach to Disease Management involves:

• Identification of patients at risk through review of loss data, self-referral, physician referral or employer referral.
• Initial risk assessment is conducted.
• Coordination and facilitation of education and self-management techniques is conducted through telephonic and/or in-person instruction in accordance with program protocols.
• Reassessment and outcomes measurement is conducted.
• Referral to case management is made as appropriate.

The focus of the program is to empower the patient as much as possible to self-manage their disease through knowledge of its causes and triggers, how medications work, other treatment options and understanding when to seek the advice of their physician.
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Information System/Statistical Reports

The complexities of our ever transitioning health benefit marketplace, along with the inherent need to provide employers and insurers with the tools to contain cost, place technological demands on program administrators and medical managers. The ability to document patient and provider contacts, clinical findings and notes is critical to the effective management of medical activity. As well, data maintenance and sophisticated reporting systems permit medical managers to monitor, analyze and communicate information about expenditures, savings and general and specific claim experience.

To meet these demands, and to integrate medical management and claims activities on a "real-time" basis, Spectrum Administrators, employs the Medical Management module of the Resource Information Management Systems (RIMS). This allows Spectrum Administrators' medical management department staff to review and exchange live information with the Spectrum Administration claims and customer service departments, and, with the modules directly linking eligibility, payment data, customer service contacts and benefit plan parameters, there is seamless access to all facets of a client’s program.

Spectrum Administrators has devised a series of reports to present utilization and contact information. Standard medical management reports include:

• UTILIZATION REPORTS
  Detailing both inpatient & outpatient activity.
• CALL REPORT
  Detailing call activity for service requests.
• ADMISSIONS REPORT
  Detailing all medical/surgical inpatient admissions for a set period of time.
• MATERNITY SERVICES REPORT
  Detailing all maternity admissions scheduled after a set period of time.
• DISEASE MANAGEMENT ASSESSMENTS AND OUTCOMES REPORTS
  Varied loss trending reports used to identify potential program candidates, custom-designed, on-line health risk assessments, and outcome reports including clinical and non-clinical information.

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