When members reach 50% of the reinsurance deductible, according to the reinsurance agreement, we must be notified. The issue is timing. The finance or claims department sends notices based on claims received and/or paid, but often bills are not submitted by the medical facility until the member is discharged, after the claim has reached or exceeded the 50% level. Summit ReSources would like to help reduce your costs; however, once claims are paid, it is harder to intervene with cost-reducing strategies. Usually your medical management department is aware of a potentially high-cost case because the utilization management staff are following the progress of the member and authorizing continued services. Summit Re has developed a case management notification process so that utilization management staff and case managers can notify us of potentially catastrophic, high-cost cases as soon as possible.
All of the case management notices received are reviewed by Debbie Stubbs, RN, MS, CCM to determine if there are ways to reduce cost while maintaining quality of care. Debbie will contact you to offer recommendations and alternatives.
Cases may also be referred even if there is little potential for reinsurance reimbursement if you want an objective, third-party review. Below are actual cases that were recently referred to Summit ReSources.
We are committed to helping you find cost-effective solutions. Regardless of whether the reinsurance deductible is expected to be exceeded, we encourage you to submit case management notices so we can put our resources to work for you. We have a form that can be used but will accept information in any format that works best for you. If you would like a copy of the case management notification form, please contact Debbie Stubbs.
Case Management Example 1
A member requested to go to a specific facility for cancer treatment. The facility was not in the health plan’s network but the request was approved. Global Claim Services, Inc. contacted the facility prior to services being rendered and negotiated a discount for the health plan.
Case Management Example 2
A member required surgery for congenital heart disease and the plan did not have a facility nearby that performed the necessary surgery. Summit ReSources provided the plan with information about centers with the most favorable outcomes.
Case Management Example 3
A severely burned member was facing a lengthy hospitalization with a complex treatment plan. Paradigm Health provided an assessment by physicians and nurses highly experienced in the care of burn patients and developed a plan of care in conjunction with the treating team.