Medical Management Program
Delphi’s medical management system on the surface appears much like other Utilization Review (UR) companies. However, there are substantial differences in its operation and even more importantly, the results. For example, utilization organizations doing precertification are very similar in that; they all use similar criteria, they have nurses reviewing admissions and discharges, and they all document the reasons for medical necessity.
Delphi performs all of those functions as well, but goes even further. While other UR companies stop after medical necessity is determined, Delphi considers this as the point where our work begins. We begin with working with the patient to find the best physician to perform the service and the most efficient facility to obtain the service. We review with the patient the highest quality physicians from whom they may chose, the best facilities for their treatment, and assist them in making appointments. We continue to work with the patient throughout the episode of care to make sure their care is rendered in a logical and productive manner.
The most important difference Delphi makes is that our nurses talk with patients, as well as physicians about their medical care. Our utilization review nurses are armed with both quality and cost efficiency data on each physician and medical facility. That information allows the nurse to offer the patient the best medical providers and facilities within the area. Upon precertification, our UR nurses enter into the claims system the exact services to be rendered under the precertification, and many times pre-price the expected claims. Thus, the claims person handling the claim will pay only for the services authorized.
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