Medical Management

First Choice Health’s Utilization Management Program is a core Medical Management service that is designed to promote the delivery of evidence-based and appropriate care to enrollees. Components of the program include:

• Pre-authorization: generally focuses on all elective inpatient admissions and targeted outpatient services.
• Inpatient Concurrent Review & Discharge Coordination: incorporates daily clinical rounds by a FCH Medical Director and the clinical team to identify potential gaps in care, evaluate the appropriateness of care, and assist in transition planning. Collegial calls are made by the Medical Director to the attending physician to resolve potential care gaps.
• Outpatient Gap Interventions: is a unique program that uses available claims and pharmacy data to identify and evaluate enrollees with diagnoses and care patterns that are likely to adversely impact the employee's health and workplace productivity.

Our registered nurses follow each client’s summary plan document and utilize evidence-based guidelines to inform appropriateness of services. Where appropriate, care is coordinated with FCH Case Management services.

Our client-centered Case Management program focuses on the identification of catastrophic, complex, and chronic medical management needs as identified by Utilization Management, providers, the payer/group and self-referral. We have over 20 years of Case Management experience. Our Case Managers provide a personalized and integrative approach to assist the enrollee, their caregivers, and their healthcare providers achieve the most appropriate and cost effective care.

Registered Nurse Case Managers:

• Provide free, voluntary, and confidential assistance.
• Offer telephonic support to identify needs and create a plan.
• Coordinate care with the enrollee’s health benefits plan and physician
• Help enrollees and their family to understand a diagnosis and make decisions regarding healthcare.

Experienced Masters prepared and licensed therapists assist enrollees with recovery from mental health and substance abuse problems. The program works closely with corporate benefit managers, program administrators, client/families, and providers to ensure the delivery of high quality, medically necessary case and utilization management services. Behavior Health Coordinated Care Case Managers are also able to compliment our gatekeeper Employee Assistance Programs and assist in the coordination of care.

A Behavioral Health Coordinated Care Case Manager can assist enrollees with:

• Finding a counselor or program
• Learning about mental health therapies and medicines
• Developing an individualized care plan
• Working with their team of providers
• Transition of care from an inpatient to outpatient setting

First Choice Health in partnership with American Health Holding provide an array of leading-edge Health Promotion Services. These services are offered as an integrated adjunct to Utilization and Case Management services.

The goal is to provide participants with education and tools to improve their overall health. Programs are available to assist people across the spectrum of health, from those who are currently healthy to those who are chronically ill. Programs include:

• 24/7 Nurse Line: First Choice Health provides nurse line services that enables easy confidential access to timely health education and guidance.
• 24/7 Physician Consultations: Getting expert medical advice from a doctor has never been easier. In addition to consulting with a physician by phone or secure email, this service includes a one-stop health portal that allows members to search for a specific health topic then click to consult with a doctor via phone or email.
• Maternity Management: Enrollment is voluntary and easy. Members can self refer. Contact begins early (first trimester is ideal) and continues through pregnancy and after delivery. If a high-risk enrollee is identified, case management is begun. Registered nurses educate members by phone and through the mail.
• Health Assessment and Biometric Screening: A Health Assessment (HA) is included in the Wellness Web Portal to evaluate health status and health-related productivity. The HA and biometric screening may be used as a trigger for enrollment in the Disease Management or Wellness programs, as applicable.
• Wellness Web Portal: our wellness portal is an option with on line tools to support participants to reach their personal health goals. In addition to the HA, the wellness portal includes a personal health record, 24/7 live nurse chat, health and wellness library, and other interactive easy to use tools.
• Wellness Coaching: We offer one-on-one telephonic intervention with a personal health coach to targeted members at convenient times to the employee. Our team of personal health coaches includes health professionals from a variety of backgrounds, such as dieticians, nurses, health educators and exercise physiologists. Information and counseling is geared to participant need and interest.
• Disease Management: Specific chronic disease management programs include, but are not limited to, diabetes, asthma, coronary heart disease, congestive heart failure, chronic obstructive pulmonary disease, chronic pain (back pain, osteoarthritis, and rheumatoid arthritis), hyperlipidemia, and hypertension. The customized programs provide education and support to help program participants, across all levels of illness, understand and manage their chronic diseases.

Medical management is an integral part of First Choice Health Administrators (FCHA) and provides the following additional services:

• Appeals
• Pharmacy Coordination with Pharmacy Benefit Managers
• Post–claim review for high dollar and other select claims
• Clinical expertise and review for stop loss