Care Coordination Program (UR)
Our utilization review (UR), which we call "Care Coordination Program", is very flexible. We perform a variety of levels of UR for our clients ranging from notification to inpatient/outpatient/defined diagnostics.
Our Medical Advocate ProgramSM (MAPSM) greatly enhances our ability to perform utilization reviews. Often our TPA clients will start utilization review with us and then convert their clients over to the MAPSM program. The employees will be able to use just one number to access both the precertification and MAP. And, our nurses can easily convert a UR call from the provider’s office into a MAPSM call to the patient. That allows us to get involved with the patient many times at the symptom stage where we can begin to educate and steer the patient toward better outcomes and more efficient facilities.
When Delphi administers the UR and MAPSM programs together savings to the employer are optimized.
We establish the most effective net rates on the facilities available to choose from within the network. The most effective rates are those that combine the network discounts and average charges for procedures to find the actual cost of what will be paid.
Using Delphi's proprietary database of healthcare statistics, our nurses are armed with the most effective rates in the area for imaging, radiology and other diagnostic testing. The combined program doesn't just consider whether the test is needed, but at what location and by whom the patient should be seen. In addition, a simple UR call for an MRI may trigger a follow up call to see what the results were and lead us to help the patient organize the next steps in their care.
Several re-insurers give our TPAs favored rates because we can get involved in large cases earlier and direct traffic from the very beginning before specialists and facilities are selected. Without our involvement, patients may be led to substandard specialists and overly expensive facilities . . . which is too often the case.
When a patient goes out of the network, we often coach them back and can often negotiate the eventual rate achieved favorably. This is because we are negotiating the final bill at the time the service is being rendered.
No other UR organization negotiates or that has the powerful cost information with which to negotiate effectively. Delphi's proprietary database contains current cost information on all of the facilities in the country which allows
us the ability to assess competitive hospitals and facilities in a given area as a source of proof if the facility is not being reasonable with its charges. Our TPAs will confirm that we have helped them avoid thousands of dollars in unwarranted expenditures. |
