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Medical Management Programs

Independence Administrators offers an integrated medical management program designed to assure that the health care services plan members receive are appropriate and medically necessary and meet standards for high quality and cost-effective care. We offer clients flexibility and control of their utilization management program design, working with them to develop the best medical management program to fit their member population needs.

Our medical management team consists of highly qualified, licensed health professionals with extensive clinical and medical management expertise. Using nationally recognized criteria to monitor the appropriateness of member care before, during, and after a hospital confinement, and when outpatient treatment is necessary, our medical management programs work to enhance patient health and guard against unnecessary financial expenditures. Our medical and professional staff includes in-house Medical Directors as well as RNs and other professionals who average nine years of experience in medical management. 

Benefits of Our Medical Management Program

  • efficient use of health care dollars;
  • enhanced ability to predict and budget future costs;
  • improved health outcomes and member satisfaction;
  • ability to identify and mitigate risk;
  • improved health care utilization.

URAC-accredited Utilization Management

URAC-accredited Utilization ManagementThrough AmeriHealth Administrators, we offer an in-house Utilization Management program that focuses on improving patient outcomes and reducing health care costs by addressing health care needs early and diligently. Robust, effective, and URAC-accredited, the program offers these key services:

  • precertification (inpatient, outpatient, transplant, maternity, and ancillary services)
  • concurrent review
  • retrospective admission review
  • discharge planning
  • appeals administration

URAC-accredited Case Management

URAC-accredited Case ManagementThrough AmeriHealth Administrators, we also offer a URAC-accredited Case Management program, which demonstrates a proactive, coordinated approach to support patients with complex or chronic health conditions and to help achieve the best clinical outcomes for members in the most appropriate manner.

With state-of-the-art risk management tools and diagnosis, treatment, and utilization trends, we proactively identify members at risk for serious illness that can result in high costs. Our in-house case management program facilitates health care delivery, improved outcomes, and reduced costs.

Using plan and community resources, the case management team works with members and their health care providers to develop individualized care plans and goals and to monitor progress. Case management can benefit both plan sponsors and members through improved patient outcomes and decreased preventable emergency room visits, fewer acute hospital admissions, shorter lengths-of-stay, and reduced overall utilization, where possible and appropriate.

Who Benefits From Case Management?

  • members suffering from complications of chronic diseases;
  • premature newborns with multiple health care needs;
  • victims of traumatic accident and injury;
  • members who have multiple home health care or durable medical equipment needs;
  • transplant candidates;
  • members with multiple, complex disease processes or health care needs.

The program strives to attain a balance between quality and cost-effective care, while maximizing the patient’s quality of life.

Predictive Modeling

Integrated technology and analytical tools enable us to analyze claims utilization data in relation to medical management and disease management data, and to develop predictive models that give our clients actionable information about their health plans’ performance.

Our approach identifies members who will benefit from case management, notifies plan sponsors when accumulated costs reach 50 percent of their stop-loss stipulation, and leverages information to help clients improve their benefits performance.