Solutions that are 100% automated are unlikely to produce reliable or remarkable results. Our editing solution is assembled of talented and experienced review and negotiated professionals that include certified coders, former practice managers, and customer service executives. Many of years in the industry has proven that it’s the human component of the process that finds connections where data may not, formulates pertinent questions, and interprets the results.
Out of network negotiation services include: provider signoff, medical necessity, coding, and fraud checks. The team collects medical records required for review, itemized bills, operative notes, lab orders, and supply invoices based on relevancy to the claim. They subscribe to multiple nationally recognized databases to determine the benchmarks, verify providers credentialing, board status, or sanctions in order to develop a negotiation strategy for each claim. The negotiators aim to settle each claim in a target settlement range, that is based on factors including usual and customary values, resource based relative value scale calculations, and proprietary payment data. What makes this negotiation process so unique is whereas most cost containment vendors use an automated review process, this solution uses and “eyes on every claim approach.” This maximizes opportunities to identify errors, abusive billing schemes, and potential fraud. They also negotiate directly with the medical provider to achieve a settlement at a fair market value.
Our Utilization Management program is URAC accredited program and provides medical necessity reviews that ensure members receive appropriate care while maximizing opportunities for cost savings. Members benefit from our program’s registered nurse reviewers, American Health’s board-certified medical director, an internal panel of board-certified, practicing physician specialists and an external panel of specialists.
Clinical professionals benchmark against MCG Health’s days per 1000, admits per 1000 and average length of stay criteria to certify treatments. Cases are continually monitored to ensure quality and appropriateness of care, and we report all never events and avoidable hospital conditions.
All admission evaluations and reviews are conducted by registered nurses with an average of 10 or more years of clinical experience or by board-certified physician reviewers. The review is supported by American Health’s state-of-the-art proprietary software, iSuite, that facilitates all steps in the utilization review and process and automatically makes referral to Case Management.
Our URAC-accredited Disease Management program targets nine prevalent conditions for which evidenced-based guidelines are established to impact health and measure improvements.
- Chronic kidney disease
- Chonic pain
- Coronary artery disease (CAD)
- Congestive heart failure (CHF)
- Chronic obstructive pulmonary disease (COPD)
Members with chronic conditions are identified through an advanced predictive modeling system and, once enrolled, work one-to-one with a dedicated nurse health coach.
All of our Disease Management nurse health coaches are registered nurses who have been trained in motivational interviewing techniques. Nurse health coaches identify participants’ confidence and ability to self-manage their condition using the Patient Activation Measure© assessment, developed by Insignia Health. They then help participants set individualized goals using Insignia’s Coaching for Activation© behavioral change model.
Our URAC-accredited Case Management services are designed to improve the quality of patient care while maximizing cost savings. Our Utilization Management triggers cases that may benefit from Case Management intervention, helping to facilitate early identification, prevent rehospitalization and significantly reduce costs.
Our case managers are registered nurses and licensed social workers who function as advocates, facilitators and educators, ensuring that members receive appropriate care at the right time, the right setting and the right cost.
TBG’s Experienced Clinicians:
- Collaborate with providers to ensure the member receives high-quality, cost effective care.
- Complete telephonic assessment that assist in determining the member’s needs and requirements.
- Review treatment plans for medical necessity and standards of care.
- Help Members and their families understand what to expect during the course of treatment.
- Supply educational materials about treatment options.
Our Wellness programs are a solution for employers who are looking to reduce future health care expenses. Targeting both healthy individuals and those who are at risk of developing a chronic condition, American Health’s Wellness programs help members achieve healthier lifestyle behaviors through a Wellness Portal, Biometric Testing and Lifestyle Coaching.
TBG’s Wellness Portal provides a wide range of online resources focused on member-specific needs. Key features include a health risk assessment, personal health record, health trackers, symptom checker, rewards center, online digital coaching, drug guide and a wealth of other decision-support tools.
- Weight Control
- Tobacco Cessation
- Healthy Eating
- Physical Activity
- Stress Management
Onsite or offsite biometric testing options are available to help members understand potential health risks and increase engagement through the use of the Wellness Portal and Lifestyle Coaching.
Through a dedicated, one-to-one coaching approach via telephone and through the Wellness Portal, Lifestyle Coaching utilizes the latest behavior-change science and highly credentialed health professionals to drive sustainable health outcomes.