Clinical Care Management
Effective Clinical Management can influence costs by anywhere from 2% to 5% of claims

Clinical Care Management is an important element to be considered in cost management. However, putting first things first, Clinical Care Management is a second seat or another conversation. Networks compared to Out-of-Network influences costs upward 1,000%.
All major health plans offer strong clinical management and emphasize aspects of helping to get patients the right care at the right time in the right treatment setting, balancing cost and quality.

Some questions include:
Does the cost management process focus on so-called high-cost claimants? What is the target threshold? What triggers care management activity?

Independent claims oversight creates a strong foundation - but more impactful savings opportunities come from proactively managing healthcare consumption. The most effective clinical strategies reduce overall health risks, prevent unnecessary claims and encourage utilization of high-value facilities. Legacy healthcare programs include some level of case management support for employees facing serious and long-term health issues. However, all programs are not created equal. These legacy programs face a lack of meaningful employee engagement and instead rely on the administrative functions of verifying network status and medical necessity. This puts cost savings and employee health at risk. On the other hand, best in class health plans include a collaborative process of assessment, coordination, evaluation and advocacy to meet individual and family health needs and maximize lower risk for expensive or catastrophic claims. The result for these companies is better overall health and managed spending. In 2018 companies achieved lower rates of inpatient days and hospital admissions.

Audit your clinical strategy for:

  • Outreach that's integrated with your health plan in real time
  • Successful engagement rates with clear definitions
  • Intervention strategy based on real-time and comprehensive stratified risk data
  • Detailed case reviews and independent prior authorization
  • Clear communication with employees that builds trust
  • Seamless coordination with reinsurance carriers
  • Evaluation of alternative treatment settings