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Case Management Disease Management Utilization Management - Prior Authorization  
 
Health Management Services

Since 1999, DDHC, a physician-driven organization, has provided medical management services for small- to mid-sized employee populations.  One unique feature of our product is the direct engagement of personal physicians into employer-directed healthcare delivery. The emphasis on the physician/patient relationship and "back-to-basic" medical principles is the driving force behind the best possible outcomes, all of which is synergistically mediated by DDHC. The result: healthy patients (employees), happy physicians, and satisfied employers.

Pre-authorization of Outpatient Services

Pre-authorization of high-cost, high-volume procedures and surgeries based on:
  • Quality of care
  • Medical necessity
  • Patient safety
  • Cost effectiveness

Pre-authorization of Inpatient Services

Pre-authorization of Planned Hospital Admission

Ensure that services are provided in cost-effective setting when medically necessary.

Approve care utilizing evidence-based guidelines focused on assessment and outcome criteria.

  • InterQual Criteria
  • Milliman Guidelines
  • Medical Management Programs
  • Utilization Management Committee
  • Quality Management Committee
  • Physician Education Committee 

 

Case Management

Proactive initiative to identify patients who may benefit from case management that incorporates appropriate quality care, safety and cost effectiveness.
  • High-cost cases requiring long periods of care (Cancer, Spinal Cord Injury, MS, etc.)
  • Cases that require intense, short-term services (Premature Infant, Post-op Orthopedics, etc.)
  • Coordination of services throughout the continuum of care to include:
  • Inpatient reviews and discharge planning
  • Arranging alternate outpatient care
  • Negotiating rates for equipment/services

 Disease Management

DDHC has a comprehensive disease management program designed to be “opt out” instead of “opt in”. In other words, members identified by medical/rx claims or through the wellness screening are included in educational mailings and compliance reviews, unless the member chooses to “opt out”.

Focus is placed on the “bang-for-your-buck” programs such as Diabetes, Asthma and Cardiac, which includes all forms of Heart Disease, High Blood Pressure, and High Cholesterol.

The disease management program is a physician-coordinated team approach in managing a chronic illness that requires continuing medical care. The disease managers communicate with the physician regarding compliance, plan of care, and special needs of the member. The goal is to educate the member about managing the disease process; therefore, preventing acute complications and reducing the risk of long-term complications.

The Disease Management Program is tailored for each client based on data analysis of the historical medical and RX claims experience, along with the wellness screening data.

Potential candidates for the disease management program are identified through proactive identification. Members may be identified through the pre-authorization process, member or provider referral and Health Risk Assessment screenings. Monthly reviews of the medical and RX claims paid data also help identify members who will benefit from disease-specific education and guidance.

The disease manager uses various methods to contact and engage the member in the program including phone calls, emails, mailings, website/internet tools and on-site RN visits. The goal of the program is support, education, compliance, and improved outcomes. 

 

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