Scope of Services:
Case Management | Utilization Management | Disease Management | Medical Underwriting/Cost Projections
Medical Underwriting/Cost Projections | NEW! Underwriting | Claims Management | Medical Review
Our Case Management Program is fully integrated with our utilization and disease management programs, which provides member-specific interventions to high-risk participants. We provide registered nurse case managers who oversee the entire spectrum of healthcare services for individual members. This process helps maximize a member’s insurance benefits, which ultimately supports optimal cost savings. We educate members about the benefits of receiving the highest quality of medical care, cost effective treatment and living a healthy lifestyle. We evaluate the member's medical care on a regular basis, and as needed.
We provide comprehensive, easy to read Case Management Reports and have the ability to provide all Case Management services or provide back-up to a Case Management staff that is already in place. We have staff that has worked in the reinsurance and insurance industry – so they are knowledgeable about their needs.
The scope of the Utilization Management Program is to monitor and evaluate the appropriateness of care for all services provided to all members at all levels of care. We are committed to quality of care for all members served. Our program includes (but is not limited to) prospective review, concurrent review, retrospective review services and discharge planning. This complete process enables CPR Risk Management to ensure that members are receiving high quality and appropriate care while managing high cost care and hospitalizations. Our automated trigger diagnosis program identifies members with certain chronic conditions and catastrophic diagnoses, which are referred to either our Case Management or Disease Management Programs.
We educate members with complex, chronic conditions about improved self-management skills, disease knowledge and life-style changes. Our program offers members education regarding six chronic diseases: Diabetes, Coronary Artery Disease, Chronic Obstructive Pulmonary Disease, Asthma, Hypertension and Congestive Heart Failure. Many members have more than one chronic condition and our program is designed to provide the skills needed to manage all of their healthcare needs. We provide individual empowerment, with interventions customized to the particular member.
Medical Underwriting/Cost Projections
Our medical underwriting services provide an independent assessment of the medical risk. We have registered nurses working with underwriters to provide claim projections for prospective and renewal cases. Our turn-around time is normally 24 hours, and guaranteed at 48 hours. We understand how important turn-around time is for the underwriters to be able to respond to their agents, especially during peak underwriting periods. We understand risk and have the clinical expertise to be able to provide cost projections on known claimants. We are knowledgeable in assessing risk for both stop loss and first dollar medical programs.
Our Underwriting services include Stop loss and Fully Insured underwriting, Underwriting audit functions, Specific and Aggregate claim audit assistance, Captive underwriting functions, and Block analysis. These Underwriting services will be offered with the same promptness, reliability and professionalism that our clients have come to expect.
CPR provides clients with claim reviews to assess for appropriateness of charges, pre-existing conditions and medical necessity. Oversight claims management can also be provided to assist with setting case reserves based on known medical conditions or diagnoses. CPR assists with managing claims through our various medical management programs, or can coordinate these services through its client’s vendors. Specialty networks for transplant, cancer, dialysis and high cost pharmaceuticals are available through CPR. Out-of-Network claim management, utilizing CPR’s highly specialized negotiators, allows significant cost savings for our clients. Our bill review services evaluate medical claims for potential provider billing errors and inaccuracies and are provided for both In-Network and Out-of-Network claims. By applying the highest caliber of staff, technology and operational processes in the industry, CPR has a proven track record of excellent results and substantial savings for inpatient, outpatient and dialysis claims. This can ultimately improve our clients’ results and may reduce or eliminate the need for lasers. (depending on the spec, contract type, etc.)
We offer medical review services prospectively and retrospectively when a medical service or claim requires review for appropriateness. We utilize a panel of specialty physicians who evaluate recommended treatments or services to assess appropriateness and medical necessity of treatment. These services can be utilized to determine if a treatment is experimental or investigational, if coding is accurate and charges are appropriate, off-label usage of medications, standard of care and many other types of treatment or claim questions.