Akeso^® FAQ

• Utilization Management
• Case Management
• Out of Network Claim Negotiation
• Medical Bill Audit/Review

Utilization Management

What is the goal of UM? Isn’t it just more ”insurance red tape”?

The key to a successful Medical Management program is early identification and action. UM provides the best tool for the initial identification of a patient’s entry into the health care system. This allows the ACM^® medical management staff to be proactive in working with both the patient and their providers to assure delivery of healthcare in the most appropriate and cost effective manner.

How does UM reduce overall healthcare costs for the employer and insured?

Early identification allows ACM to work directly with the patient and the provider to assure that the care is being delivered in the most appropriate and cost effective setting. UM impacts care and costs in many ways, including: direction to an in-network PPO provider (PPO Channeling); determining the optimal length of stay (M&R; Care Guidelines), avoiding unnecessary hospital days; concurrent review; collaborative discharge planning with both the patient and provider to assure that all the patient’s healthcare needs are in place thereby avoiding delays in discharge and/or a readmission; and initial identification of case management opportunities; naming only a few.

Why does ACM recommend Pre-Certification for outpatient services?

Due to advancements in medicine and the delivery of healthcare, many very complex and expensive treatments are now done in an outpatient setting. Pre-certification of outpatient services allows ACM an opportunity to impact healthcare costs prior to receipt of the claim when the opportunity for proactive involvement has been lost.

Case Management

Why is case management necessary? How can a nurse know what is better for a patient than the patient’s physician?

The U.S. health system is anything but a “system”. It is a multitude of providers all functioning independently without any coordination. Because most patients in Case Management are in the active care of several independent providers, these patients are those most likely to suffer from this lack of provider coordination. The Case Manager assumes this role as “coordinator”, assisting the patient and providers in developing a collaborative approach to their care. The Case Manager’s efforts assist in cost containment by PPO channeling; minimizing the chances of duplicate testing; rate negotiation; appropriate hospital stays; discharge planning; etc.

How does the patient/insured react to Case Management?

When a person is facing a medical situation that has caused them to be considered for case management, they are often overwhelmed by the prospects facing them. ACM Case Managers assume the necessary role of patient advocate. We work with the patient to educate them on both the illness and treatments and how they can best utilize and stay compliant with their healthcare benefits. ACM assists the patient in the development and understanding of their “roadmap” to care. We find that patients in ACM Case Management embrace the program and often find it to be one of the most valued benefits of their healthcare coverage.

Is ACM able to get providers to cooperate with Case Management efforts?

Providers are normally agreeable to the Case Management process. In much the same way that the patient is assisted in coordination of their overall care, the providers enjoy many of the same benefits. Additionally, it also allows the provider a central contact point with the insurer to better determine and comply with the patient’s healthcare benefits, therefore, avoiding potential reimbursement issues.

Out of Network Claim Negotiation

Why do you need to negotiate fees if we already have a PPO provider?

Although there are thousands of PPOs in the United States , there are none who have every provider under a contractual relationship. Patients may seek treatment from one of these providers and, without negotiation, your payment will be based upon the provider’s billed charges.

How do we get providers to negotiate fees?

Although each situation is unique, nearly all providers have some contractual relationships in place and understand that discounting of their fees is expected. If an insured seeks treatment from a non-contracted provider, these providers will often negotiate rates for any number of reasons. These may include: lessening of payment burden on the insured if coinsurance is applicable; prompt payment guarantees; retaining patient if treatment is to be ongoing; prospect that U&C; may be applied; or, many times, simply that we asked.

What types of discounts can be expected?

Because each situation is unique, answers to this question can vary widely. Discounts can range from as little as 5% to as much as 75% for some high-cost infusion therapies.

Medical Bill Audit/Review

Do bills really need to be audited?

Yes. As reported by the Wall Street Journal, 98% of all hospital bills contain errors, 75% of these errors are unfavorable to the paying party.

How is it determined that a bill is a good candidate for audit?

For claims between $20,000 - $50,000, ACM recommends they be reviewed for audit potential. For any claim > $50,000, ACM recommends a full audit.

What type of savings can be expected when a bill is deemed to be a good candidate for audit?

Although each situation is unique, ACM has found that a minimum of 12-15% can be saved when an audit is conducted.