Companies like yours value a strong commitment to containing claims cost. Our high touch method creates an individualized approach to improve outcomes and reduce costs. The more claims cost is contained, the more financially strong you may be.
What's important about that? As you enjoy Critique's ROI on Utilization Management Services at 14:1.... you may find.... it's 3 times the national average.
The more Critique contains costs, the more profitable you may be. The more profitable you are, the better benefits you may offer to retain
valuable employees.
A Pre-admission Certification request triggers co-operation between our nurses, the patient, doctor, and healthcare facility. It can prevent
unnecessary hospital days and ensure that treatment is managed effectively and is consistent with medical necessity. The purpose of pre-admission certification is to:
- • Confirm necessity of hospital stay
- • Determine appropriate number of hospital days
- • Recommend alternative health care or facility as appropriate
- • Discourage non-emergency weekend admissions
- • Encourage pre-admission testing
- • Identify potential catastrophic illness or catastrophic accidents
A part of the process is active Concurrent Stay Review. As Critique’s nurses follow the patient throughout the hospital stay, you may find patients are discharged as soon as it is safe to do so. Naturally patients may be discharged with home health nursing assistance, home IV therapies, family care training and support which is planned with the patients’ medical team. If the patient’s condition requires a longer stay than originally planned, additional days are authorized and made a part of the discharge plan.
Critique begins the discharge planning on the first day of hospitalization. The discharge plan allows for continued medical care, after hospitalization if the patient’s condition indicates such a need. The plan may include placement of NurseMonitor™ equipment and monitoring or other durable medical equipment along with home health services for support and training or placement in a qualified “step-down” facility.
Out-patient Utilization Managementfor Medical Necessity is a simple process, which serves as a “sentinel” for adherence to protocols for determining medical necessity. As with pre-cert admission, the doctor, healthcare facility, or authorized patient representative makes a toll-free phone call and responds to a brief set of questions for the following purpose:
- • Conduct an interview to determine adherence to medical protocols;
- • Establish medical necessity of requested procedures;
- • Determine appropriate medical codes;
- • Advise and disclaim that there is no guarantee of benefits;
- • Encourage a second opinion if medically questionable;
- • Rule out cosmetic application of requested procedures.