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hospitals for high quality employees and the need
to provide competitive benefits while focused on managing
utilization. We have also been successful in helping our clients
integrate the use of a wide range of domestic services into the benefit
plan. Some of our capabilities with hospitals include:
- Administering a 3-tier benefit plan with
domestic utilization as the highest level, a PPO as the second level
and an out-of-network benefit level;
- Related to the domestic benefit level, direct contracting with highly utilized providers;
- Special rules for pre-certification if using
the domestic benefit and/or use of the hospital’s discharge
planners as a the primary source of managing admissions at the hospital;
- Coordination of wellness, prevention and disease management programs with the hospital’s health educators;
- Working with the hospital to create an
“urgent care” benefit for low intensity use of the
hospital’s emergency room;
- Receipt of electronic claims directly from the hospital;
- Issuing of remittances only for claims within the hospital system, versus standard checks and explanations of payment;
- Working with the hospital to use the
hospital’s outpatient pharmacy as the primary source of obtaining
prescriptions for the employees. This includes use of a pharmacy
benefit manager and “pass through” pricing for drugs; and
- Special management reporting detailing use of the various benefit levels and types of care received outside the hospital.
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