Care Management
ENCOMPASS Health Management Systems, together with our parent company, the Iowa Foundation for Medical Care (IFMC), provides a wide range of integrated Care Management, Quality Management and Information Management.
IFMC's Care Management services are built around the concept of providing the right health management services at the right time and in the right combination. We provide customized managed care programs to self-insured employers, insurance carriers, health and welfare trusts, third-party administrators, municipalities and preferred provider organizations.
A full range of flexible services enables our company to address all aspects of an organization's care management needs while working to empower individuals to make the best choices about their care:
- Customizing program solutions for each client
- Improving outcomes by supporting right care, right time, right setting initiatives
- Demonstrating value in terms of care, quality and cost improvements
Our Care Management services include:
Medical Management
Our approach to Medical Management facilitates medically appropriate and necessary health care services. Our nurses apply proprietary screening criteria to each case, evaluating medical necessity and treatment setting. If criteria are not met, cases are referred to one of our 180 provider consultants across the country for a determination of medical necessity.
Utilization Management. Review of inpatient and/or outpatient services, procedures, supplies and pharmacy requests with a recommendation of medical necessity and appropriateness based on clinical information and physician support to promote care delivery at the right time, the right place and the right setting.
Independent Review/ Specialty Review. Review of services, procedures and supplies to address medical necessity and/or experimental/investigational treatment requests based on clinical and reference information and physician support.
Disability Review, Absence Management and Workers' Compensation Review. Review of inpatient, outpatient and ambulatory services, procedures and supplies for persons with occupational and work-related injuries and disabilities; including coordination with lost time, modified duty and return-to-work initiatives.
Care Coordination
Health plan members face many challenges when a medical condition affects their daily life. Increasing medical risks and deteriorating health can lead to disruptions and limitations for members while draining their individual plan benefits. It can also place financial strain on a health plan. To assist with these health challenges, our company offers many types of Care Coordination programs, each developed to address people with different care needs.
Case Management. Individualized care coordination interventions for persons experiencing acute and catastrophic events.
Chronic Care. Individualized care interventions for persons with multiple medical conditions who are experiencing limitations to activities, deteriorating health and high utilization of medical services.
Disease Management. Coordinated health care interventions and communications for persons with specific conditions for which education and self-care are a primary focus.
Maternity Management. Health assessments with education during pregnancy; including identification of women at risk with implementation of individualized care coordination programs to address risk for a normal delivery
Transplant Management. Individualized care interventions for persons at any stage for organ or tissue transplant; including coordination with facilities, providers and health plan administration
Care Navigation. A broad range of integrated care coordination programs designed to improve health outcomes for persons according to their individual health needs
Integrated Services and Demonstrated Value
Our proprietary member-centric information system supports integrated and progressive care coordination which include the following attributes:
Network providers channeling
Real-time data exchange with third party administrators
Implementation of 40 different transmission formats – including HIPAA ANSI 278
Medical records, faxes, and correspondence electronically attached to member record
Client savings and activity reports
Medical Management program reports document utilization, health plan savings, provider activity and medical trends with comparison to national normative information. Care Coordination programs value is demonstrated through actionable report packages documenting outcomes and savings. All reports are specific to the individual health plan or client. Our standard report package includes analysis of program to market trends, recommendations regarding plan design/member education and comparison to book-of-business and national normative data.
Quality Oversight
Our dedicated Quality Management department has oversight for the following areas:
Continuous auditing of nurse, provider and call center actions
Evaluation of complaints
Oversight for criteria, policies and procedures
Training and continuing education for staff and provider consultants
Review of patient safety and quality indicators
Elimination of exposure to potential compliance and legal challenges
Distribution and evaluation of member satisfaction surveys
Oversight for continuous improvement projects
To help ensure our services conform to best practices in the industry, several Health Management programs, including Health Utilization Management, Case Management, Workers' Compensation Utilization Management and Disease Management, are accredited by URAC (also known as the American Accreditation HealthCare Commission) through IFMC subsidiary, ENCOMPASS.
Additionally, ENCOMPASS is licensed or certified to provide Utilization Management services in all 50 states. Program capabilities include compliance with DoL (Department of Labor) regulations for ERISA and group plans as well as compliance with state insurance regulations, and adherence with HIPAA confidentiality and security regulations.
For more information about IFMC's Care Management Services, contact us at information@ifmc.org or read more under our services section.