CATASTROPHIC AND DISEASE CASE MANAGEMENT

Medical Case Management

When a client elects to have OCFMC provide case management, medical care coordinators are provided as necessary. Coordinators work with the patients, their families and medical care providers to develop treatment plans for the specific needs of the patient. The case manager will identify the most cost effective way to deliver the necessary services in an efficient quality focused manner.

Plans may include:

• A comprehensive medical evaluation
• Outline of specific treatment goals
• Concise plan of action around whit the patient, family, doctor, employer and health plan provider can focus efforts

Case Management is particularly effective for self funded organizations with re-insurance stop loss carriers in that it is tailored to working with the providers in containing costs, often generating savings that keep the annual amounts below trigger levels. Cost containment while an important factor is never at the expense sound medical management of the patient.

Catastrophic Case Management & Disease Management

The Orange County Foundation for Medical Care provides Catastrophic or potential large claim loss Case Management services, as a component of its Utilization Management Division. The Case Managers, Physicians and staff affiliated with the Foundation and its Catastrophic and Disease Case Management division are dedicated to providing compassionate, caring and medically sound options for patient care. We are committed to helping our patients through the Health Care system and having them as informed as possible so the choices they are asked to make are educated and in their best interest.

Catastrophic Case Management and Disease Management are highly individualized services in which the Registered Nurse Case Manager is in frequent telephone contact with the patient or patient’s family, treating and/or consulting physicians and all appropriate providers of service. On certain identified illnesses, Disease Management, a more intensive patient oriented and lifestyle change management is also employed.

The “Cost Benefit analysis “of Case Management is determined by dividing the actual cost savings obtained by the cost of managing the case (the number of billed hours times the case management rate) and expressing that as a return on investment (ROI).
An average case usually runs between six and ten months to fully assess and implement changes and the average return on investment is approximately six dollars saved to every one dollar spent in management although that is variable depending on the type of case under management.

Examples of Illnesses:

The Foundation provides individual case-by-case services to clients based on separate hourly rates for the Registered Nurse Case Manager and for consultation with the Physician Medical Director. Consultation with the designated client representative is always available for unscheduled updates or when a plan involves considering an ‘extra contractual’ expenditure option to generate savings.

Case Management – Fee Negotiation

On occasion large bills are received by a payer that fall outside the network or other discount plans. These can be originated by hospital, physician or provider and usually represent charges substantially in excess of usual, reasonable and customary. Out-of Network providers make up the largest component of bills available for direct negotiations by a Case Manager specializing in fee negotiation. The client determines if they want to employ Fee Negotiation after reviewing the bill and contacts the Foundation to take on the case.

Each bill presented for negotiation is reviewed for appropriateness of charges and then a call is made to the financial division of the agency involved offering a percent off the billed charges in exchange for concessions by the payer which include but are not limited to:

Rapid turnaround of the discounted payment
Provision for no audit on claim in question
Provision for pre-negotiated rates if it is an ongoing case