Medical Management Program
Inter-County Student Health Plan includes an integrated medical management program.
Our medical management program works to enhance patient health and guard against unnecessary financial expenditures using nationally recognized criteria. These criteria allow the medical management program team to monitor the appropriateness of member care before, during, and after a hospital confinement and when outpatient treatment is necessary.
Benefits of our Medical Management Program:
- efficient use of health care dollars;
- enhanced ability to predict and budget future costs;
- improved health outcomes and member satisfaction;
- ability to identify and mitigate risk;
- improved health care utilization.
Our medical management team consists of highly qualified, licensed health professionals with extensive clinical and medical management expertise. Our medical and professional staff includes in-house medical directors, registered nurses, and other professionals who average nine years of experience in medical management.
Components of our Medical Management Program:
- URAC-accredited Health Utilization Management
- URAC-accredited Case Management
- Maternity Management and Education
URAC-accredited Health Utilization Management
Through our affiliate, AmeriHealth Administrators, we include an in-house Health Utilization Management program that focuses on improving patient outcomes and reducing health care costs by addressing members’ health care needs early and diligently. Robust, effective, and URAC -accredited, the program offers these key services:
- precertification (inpatient, outpatient, transplant, maternity, and ancillary services)
- concurrent review
- retrospective review
- discharge planning
- appeals administration
URAC-accredited Case Management
Through our affiliate, AmeriHealth Administrators, we also include a URAC-accredited Case Management program, which demonstrates a proactive, coordinated approach to support patients with complex or chronic health conditions. The program aims to help targeted members achieve the best clinical outcomes in the most appropriate manner.
By using state-of-the-art risk management tools and applying diagnosis, treatment, and utilization trends, we proactively identify members at risk for serious illness that can result in high costs. The case management team then works with these members and their health care providers to:
- develop individualized care plans
- set health improvement goals
- monitor progress
Case management can benefit both plan sponsors and members through improved patient outcomes, decreased preventable emergency room visits, fewer acute hospital admissions, shorter hospital lengths of stay, and reduced overall utilization, where possible and appropriate.
The program strives to attain a balance between quality and cost-effective care, while maximizing the patient’s quality of life.
Maternity Management and Education
The Baby BeginningsSM program supports women throughout pregnancy and up to six weeks after delivery. Healthy pregnancies can result in fewer complications and premature births, increased birth weight, less workplace absenteeism, and reduced claim costs. A Baby Beginnings obstetrical nurse works with the participant and her health care provider to promote healthy behaviors and identify possible health risks.
The Baby Beginnings program helps make the pregnancy experience a healthy and happy one by offering:
- confidential pregnancy assessments including follow-up and outreach to enrolled participants;
- a comprehensive book about pregnancy, delivery, and baby care;
- educational information tailored to the participant’s needs including interactive web-based tools;
- a 24/7 support line where nurses specializing in maternity and baby care are available to answer questions;
- free text messages to provide information about pregnancy and baby care;
- post-delivery screening.
Baby Beginnings case management is available to support special cases in the event that a participant develops complications with her pregnancy. An experienced maternity nurse will work closely with the participant and her health care provider to help provide support, answer questions, and assist with any special needs.
In addition, women who are thinking about becoming pregnant can enroll in the preconception program, which is designed to help potential mothers make the best decisions about health, nutrition, and lifestyle habits before they become pregnant.
