by Carol Neill
Director, Claims Administration
HM Insurance Group

Everywhere you turn there’s someone talking about rising healthcare costs, revisions to policy in the insurance industry or changes in traditional medical care. When you’re involved in managing the costs related to stop loss insurance claims, it doesn’t take long to see a trend in rising fees and hidden expenses associated with medical care and procedures. With this in mind, it is important for excess risk insurers to find balance in ensuring appropriate patient care while containing the expenses involved with proper treatment. In the current environment, the historical means of medical management may not be enough to make a significant impact on expenses, and new or additional techniques must be employed.

by Jennifer B. Meko, MD
Western Region Medical Director
MedSolutions

With growing pressures to reduce healthcare costs and maintain quality, medical management companies now offer multiple solutions that include case management, disease management and utilization management services. These care management portfolios are designed to drive patient behavioral health changes, promote physician compliance with evidenced based guidelines, and introduce controls that will drive not only appropriate utilization of services but also quality care.

by Jack Hurley
Vice President of Sales & Marketing
MCM Solutions, Inc.

Since the mid 1980s , Medical Management Companies have been providing health plan sponsors and plan participants with cost containment solutions. The genesis was Hospital Review and Certification. Services quickly segued into Large Case Management and to full surgical and outpatient services. These programs were and remain vital tools in controlling unnecessary medical cost and assuring good medical outcomes. I would submit to you that medical management organizations have actually caused behavioral modification to occur in the medical delivery community.

by Matthew Haddad,
President and CEO
Medversant

Physician credentialing is generating a heightened level of attention throughout the healthcare industry in the wake of new standards and accelerating trends. New Joint Commission (formerly Joint Commission on Accreditation of Healthcare Organizations, JCAHO) requirements relating to continuous practice monitoring have prompted those responsible for the verification of key credentials to seek viable, cost-effective solutions. The stakes are high since compliance with these standards is a factor in achieving accreditation, and likely sets a new industry standard for what is prudent oversight of physicians by facilities and other organizations that employ them.

Coalition America introduced its Established Reimbursement Schedule (ERS) to the payor marketplace early in 2005.  Since its introduction, ERS has been adopted by nearly all of Coalition America's clients and has proven to create genuine savings on out-of-network claims where no PPO opportunity exists.  Historically, ERS has yielded 30% discounts on claims that otherwise were likely paid at retail or a high UCR rate.