Helping care providers control managed care costs
Ensuring uninterrupted coverage of a managed care patient’s stay in long term care or rehab can be very complex. For administrators working on very tight budgets, every benefit or reimbursement dollar that isn’t captured can directly impact your successful operations.
Our coordination of benefits across numerous practitioners and providers and assurance of post-acute managed care coverage and reimbursement at every stage provides peace of mind for patients, families, and care providers
GCHMO are experts in the managed care process. We oversee every case from referral through discharge, pursuing every coverage dollar so that all authorizations are secured and there are no surprises along the way.
THE GCHMO CASE MANAGEMENT PROCESS
- At referral time
Upon referral a full patient profile is created, and a search is initiated for available benefits and eligibility under primary and secondary insurance.
- Carveouts and exclusions
Any meds that exceed the $100/day threshold or durable medical equipment needs are identified and carveouts or a higher level of care are sought to cover the costs.
- Prior authorization
All relevant insurance carriers are rapidly contacted for prior authorizations, and diligently pursued if first or second requests are denied.
Every member is tracked for required authorization updates, and all necessary forms, notes and communications are filed with the managed care companies involved in their case.
- When things don’t go as planned…
It happens—sometimes members’ benefits sometimes get cut or coverage gets denied. GCHMO are experts at handling appeals and scheduling peer-to-peer reviews to establish necessity. Every available procedural step is taken to get coverage restored and denials rescinded.
- Medicare Part B and custodial authorizations
Any necessary additional authorizations are obtained for members who require outpatient therapy or a custodial stay, and who are covered by a managed care organization. We identify needed authorizations, perform any required evaluations, obtain renewals, handle payor changes and any other related issues that may arise during a managed care patient stay.