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Medical Management
Our Medical Management Department is URAC Accredited for Case Management
and Health Utilization Management and features an experienced clinical team with a full-time
onsite Medical Director. First Choice Health offers a full spectrum of Medical Management
services, including:
Utilization Management
The general focus of Precertification is on all elective
inpatient admissions and targeted impactable outpatient services.
Inpatient Concurrent Review & Discharge Coordination incorporates
daily clinical rounds by the FCH Medical Director and clinical team to identify potential
gaps in care and evaluate appropriateness of care.
Outpatient Gap Interventions is a unique program that uses
available claims and pharmacy data to identify enrollees with diagnoses and care patterns
that are likely to adversely impact the employee's health and workplace productivity.
The attending practitioners of identified enrollees benefit from a phone conference
with FCH's Medical Director to evaluate treatment effectiveness and options. For examples
of Outpatient Gap Interventions, click
here.
FCH's approach to addressing health care gaps via inpatient
concurrent review and outpatient gap interventions significantly differentiates us in
the marketplace. It is a collegial approach that is appreciated by the provider community
and brings outstanding results of enhanced care coordination, improved employee productivity,
and health care dollars saved.
Comprehensive Case Management
FCH Case Managers interface with patients, families, treating
providers, and facilities to coordinate patient-focused treatment plans that incorporate
judicious use of benefit dollars. Care plans include personal support for the patient
and family, assistance in obtaining necessary medical services and equipment, and consideration
of customized care options. Case Managers are instrumental in assisting patients and
their families as they navigate the complexities of the health care system.
Mental Health/Chemical Dependency
First Choice Health is uniquely poised to respond to the rapidly
growing demand for effective, professional management of behavioral healthcare services.
Our internally developed program is called FCH Behavioral Health Coordinated Care. In
addition to a menu of world-class employee assistance program services, FCH delivers
flexible options for pre-certification, authorization, gatekeeper functions, depression
disease management, and utilization review of inpatient and outpatient mental health
and chemical dependency treatment.
Clinical Appeals & External Review
FCH Provides timely evidence-based medical appeals review
by specialty-matched health care professionals via our partnership with AllMed, a URAC
accredited peer review organization.
FCH has shown an excellent response time for all appeals,
consistently meeting 100% compliance for the state and URAC mandated turn around times.
An access database has been created for identify and tracking all appeals. All cases,
whether received verbally or in written format, are also tracked through the MACESS
online tracking system.
Disease Management
FCH partners with CorSolutions to provide disease management
services. CorSolutions is an established, well respected, and NCQA accredited leader
in health management. The services integrate 24/7 nurse support, biometric device monitoring,
an extensive phone library, and web-based resources including email, electronic monthly
newsletters, and a robust online community center. CorSolutions offers a complete menu
of population-based health improvement programs to address health needs across the continuum
of care.
Specific chronic disease management programs include, but are not limited to,
diabetes, asthma, coronary heart disease, congestive heart failure, chronic obstructive
pulmonary disease, and musculoskeletal disease. The customized programs provide education
and support to help program participants, across all levels of illness, understand and
manage their chronic diseases. Each of the programs encompass four main goals: identify
those individuals with specific conditions, evaluate risk levels, develop and implement
interventions to reduce risk and improve health, and systematically measure effectiveness
of interventions. CorSolutions maintains an ongoing focus on the total health of all
program participants. The programs are offered to the enrollees on a voluntary basis
and are coordinated with their physicians.
24/7 Nurse Line
FCH partners with CorSolutions to provide nurse line services.
This program enables easy confidential access to timely health education and guidance.
In addition to 24/7 telephonic nurse access, web and email access are also provided.
Well-Baby Program (Maternity Management)
FCH offers high-risk screening and management through its
partnership with Matria Healthcare, Inc., a maternity management leader with 15 years
experience. The program is called Maternalink and is NCQA accredited. It provides high-risk
obstetric screening, general and risk specific education, the 24/7 BabyLine (available
through 6 weeks postpartum), and perinatal nurse case management to assist providers
in prolonging pregnancy, improving outcomes, reducing costs, and improving member satisfaction.
The collaborative effort reduces ER, antenatal, and NICU utilization associated with
complicated pregnancies, as well as impacting an employer's rate of presenteeism and
absenteeism.
Marketing materials targeting providers and members, enrollment
specialists making regular and after hour outbound calls to identified pregnant members,
and Matria's Provider Operations staff work to enhance enrollment in Maternalink. Clients
are only charged per enrolled member who completes the initial assessment.
Participants can participate via the email, phone, or online.
Ad-hoc reports, cohort analysis of intervention reports and outcomes are available on
a customized website.
Health Risk Assessment
A free-standing Health Risk Assessment (HRA) is available
through CorSolutions to evaluate health status and health-related productivity. The
HRA may be used as a trigger for enrollment in the Lifestyle Modification, Disease Management,
or Case Management programs, as applicable.
Lifestyle Modification Program
FCH partners with CorSolutions to provide information and
educational resources for self-directed lifestyle and behavioral modifications. Patients
are identified for this program based on their response to the CorSolutions Health Risk
Assessment. The program addresses four components: sleep, nutrition, stress and fitness.
The program is used to increase awareness of how behaviors and lifestyle choices influence
health. The program provides the skills and necessary support to implement long-term
lifestyle changes to improve health. Those classified as high risk are offered enrollment
in a nurse coach program.
Employee Wellness Program
FCH partners with American Cancer Society to offer a variety
of products and services to increase employee health and wellness. Programs include
a comprehensive workplace wellness assessment, a physical activity program "Active
for Life", a workplace newsletter, and educational seminars.
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