Case Management is provided to members who have had a recent acute illness or injury that may result in excessive claims/catastrophic loss. While case managers work directly with the member to assist them with their medical and other identified needs, they also work hand in hand with both the third party administrator and stop loss carrier to keep them informed as to the member’s condition and any potential stop loss concerns that may result.
MCC utilizes trigger diagnosis to initiate case management or case management may be requested by the TPA/Employer Group. In addition to the standard trigger diagnosis listing, Managed Care Concepts also identifies members for case management services by a number of other triggers, such as members in the hospital greater than five days, members with multiple authorizations in a short time period and members who have reached 50% of spec. MCC’s own OMNI tool is utilized by the nurse case managers to assist them in identifying gaps in care and reporting in the case management process.
In addition to its catastrophic and short-term case management offerings, Managed Care Concepts also has several specialized case management programs, such as its maternity, hip and knee replacement programs. Managed Care Concepts also has a robust transplant case management offering as well.
Just as in utilization management, the goal of the right care at the right time is paramount in the case management program. Managed Care Concepts has received preferred provider status from several national stop loss carriers due to its suite of products. This recognition which carries with it additional discounts for the employer group is the result of our Case Management and Utilization Management products which work hand-in-hand with members, plan and stop loss carriers to make sure that the member, employer group and stop loss carrier receive timely care and information.