Keepingyouawake9/21/2023 Care management program auditĪn audit should include a review of processes designed to assess not only the program structure, but also program execution and the audit’s subsequent impact on health and financial outcomes. To ensure these patients receive the best possible quality and most cost-effective care, it’s important to conduct regular care management coordination and oversight audits. While claims, eligibility, and pharmacy audits are common, many employers do not evaluate the delivery of care management programs, their impact on member health, and financial outcomes. Make sure your care management program delivers resultsĬare management programs are typically delivered by your organization’s self-funded health plan, TPA or third-party vendor, and include a number of offerings that assist members along the health care continuum. Unfortunately, many care management programs fall short of these goals. It has been widely observed that a good case management process can reduce the length of stays in hospital, diminish prescription errors, reduce duplicate testing, and lower readmission rates. They also help patients to access the most appropriate level of care, coordinate services, support patients and families, and reduce unnecessary complications and costs. Focusing care management services on your sickest plan members can not only improve the patient experience, but it may also reduce duplicate services and minimize low-value or inappropriate services.Įffective care management programs are designed to ensure that medical interventions meet accepted clinical criteria for coverage under the plan. The goal of care management is to ensure members receive quality health care services in a cost-effective manner. So, a well-run care management program should always be part of your organization’s cost containment strategy. Nearly half the medical and pharmacy expenditures for a self-funded plan stem from claims for medical care for high-to-catastrophic illnesses.
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