Case Management

The impact of catastrophic illness is enormous, both financially and in terms of its effect on the quality of life for the patient and family.

NYCHSRO/MedReview’s URAC Accredited Case Management program results in costs savings, alleviates family’s emotional stress by providing alternatives in clinically complex situations where the traditional health care delivery system is not always prepared to react.

WHAT IT IS:

  • A program for complex or catastrophic illnesses (e.g., Multiple Sclerosis, AIDS, severe burns, spinal cord injury, etc.)

  • Provides a case manager who will assess a patient’s health needs and the scope of his/her contractual benefits

  • Identifies specific areas with case management potential

  • Prepares a coordinated plan of action involving all caregivers, including potential cost savings for consideration by the claim’s payer

HOW IT WORKS:

  • A nurse from the Utilization/Case Management Department performs a standardized assessment for each case that is received for pre-authorization.

  • Cases that meet criteria for case management are assigned to a nurse who contacts the treating physician and any ancillary healthcare providers to discuss the treatment plan.

  • The nurse establishes rapport with the patient and providers and monitors the provision of services to ensure that reasonable and necessary care is authorized.

  • Any discrepancies or changes from the treatment plan are investigated by the case management nurse and referred to an in-house physician for further evaluation if indicated.

  • The case manager maintains contact with the patient, family, physician and claim’s payer until the case is closed

  • Regular progress reports and cost saving analyses are obtained and sent to the claim’s payer on a quarterly basis

For more information, click here.