Group Medical Cost Containment
To what standard is your ProviderNet network credentialed?
Our physicians are credentialed to the highest industry standard (NCQA / Joint Commission). This means our employer clients and their employees and family members have the highest quality health care access.
What does it cost to lease a fully credentialed provider network?
It all depends on the geographic area, the provider reimbursement levels and ease or difficulty of procuring certain specialties. Most networks are leased at a “per employee, per month” (PEPM) rate of between $2 to $5 dollars.
How does OMCA assist Excess/Reinsurance carriers for self funded medical claims?
OMCA acts as a medical resource to the TPA and the excess / reinsurance carrier to facilitate proper adjudication of complex medical claims. When OMCA helps manage a complex/large medical case it can result in huge savings for the Excess/Reinsurance Carrier. Stopping or minimizing excessive or inappropriate medical care for claims that are in excess of attachment points results in a first dollar reduction in ultimate reimbursement.
Do TPA’s resist your involvement?
On the contrary, most TPA’s welcome the real world clinical advice OMCA offers. Medical innovations hit the market place so fast that even the best TPA’s with the latest adjudication software can benefit from the watchful eye offered by our physician advisors and registered nurse case managers.
What do you find as a weakness in PBMs?
Most PBMs do a good job at pricing and monitoring problem pharmaceutical mixtures. However, most PBMs only play lip service when it comes to the enhanced UR function necessary to question extent and duration of prescriptions. Basically, if the treating physician orders it and attests that it is “medically necessary” then the PBM will filll it. OMCA goes the extra mile to address chronic extent, duration and reasonableness of pharmaceuticals, using the latest scientific medical evidence.
What does it cost for standard and enhanced UR services?
Quoted or a PEPM basis, the rate is $2 – $4 for standard UR and $1 – $3 for enhanced UR. Enhanced UR follows a claim for 3-6 months after the initial UR procedure and our Case Managers help ensure the best outcomes for the patient and ultimately lower medical costs.
Why is URAC accreditation important?
URAC is an independent, non-profit organization that is well known as a leader in promoting health care quality through its accreditation, education and measurement programs. OMCA’s URAC accreditation for Health Utilization Management demonstrates our commitment to quality, accountability and efficiency of health care management.
If you need further assistance or clarification on any of these answers, call the Client Services Department at (502)495-5040, or 1-800-KYCOMP-1 (1-800-592-6671)
From our Clients & Colleagues
Don McNay McNay Financial Services
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