Medical Cost Containment

“Getting the most out of your healthcare investment.”

Large Case Management

Spending several million dollars on health care and then “hoping for the best” is probably not the best strategy. There are a number of efforts put forth to reduce the amount spent by a plan, e.g. networks, utilization review, pharmacy controls, etc. Another very important effort is large case management.

Group medical programs generally don’t have adjusters like other insurance programs have. Most often they have claims processors but, for the most part, there is no one to see that the care a patient receives is timely, effective and coordinated with all relevant providers. That often means cases just take on a life of their own and move forward with no coordination and much wasted time and effort.

That’s why the role of the case manager can be so important in reducing costs associated with hospitals stays, surgeries and a number of chronic illnesses. The nurse case manager can help see that specialty referrals are made promptly, that the patient understands the details of the doctors instructions and that orders for prescription drugs are followed to enhance recovery. The ultimate goal of the nurse case manager is to assist the patient in returning to optimal health as soon as possible – and that saves money for everyone!

OMCA has a team of registered nurses who are Certified Case Managers. Collectively, we have managed over 100,000 cases in 20 years. There are a number of tools used by our Case Managers but perhaps the one that’s most valuable is their knowledge of the healthcare system, how to move someone through it effectively and expeditiously and what questions to ask.

Frequently individuals faced with illness and hospitalization are frightened and anxious and don’t always hear everything the doctor has to say – or know what questions to ask. Nurse Case Managers are excellent at help the patient get the right instructions and in getting the instructions right. They are perfectly suited by education and temperament to help assure good communications amongst all relevant parties. And they’re great at getting things done! Other tools that our Nurse Case Managers might access are:

Centers of Excellence – Nothing saves money like great care and great care often comes from facilities that have devoted extra effort to understanding and treating a particular disease process. For instance, some facilities specialize in heart care and have better outcomes than those that don’t. It’s OMCA’s job to help identify those Centers of Excellence and, when possible, see that your patient is treated where the outcomes are the best.

Disease Management – Proactive management of diseases reduces complications and saves money for all concerned. OMCA has specific programs that can help better manage chronic diseases such diabetes and congestive heart disease.

Patient Accountability and Compliance – Compliance with pharmaceutical treatment plan, communication amongst a variety of treating physicians, and specialty referrals. Nurse Case Managers get the most out of your millions in health care investment by holding the patient and physician accountable.

Contact Rosalie Faris, RN, BSN, CCM, COHN-S for further questions atrosalie.faris@omca.biz

From our Clients & Colleagues

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