Our customers may access a broad range of value-added services through Summit ReSources. These services are designed to offer cost savings, primarily through appropriate care management that is focused on clinical outcomes. If you have any questions about our managed care services or would simply like to discuss them further, please contact Debbie Stubbs, Director, Managed Care Services.
Summit ReSources' case management service has been structured to complement and enhance your own case management program. Our managed care specialists, certified case managers, are available as a resource to:
• Help assess catastrophic cases
• Provide information on rare or unusual clinical situations
• Suggest alternative care options
• Distribute information that may be useful to your medical management team
Summit ReSources' managed care specialists are available to provide an energizing, half-day case management seminar for which attendees may receive 3.5 continuing education units through the Commission for Case Manager Certification. The seminar is available to Summit Re clients at no cost.
Our customers have a variety of options that are available through our long-standing relationship with OptumHealth Care Solutions. OptumHealth's Transplant Resource Services (TRS) offers consulting expertise and access to the nation's most prestigious medical centers specializing in organ and tissue transplantation.
TRS includes:
THE OPTUMHEALTH TRANSPLANT CENTERS OF EXCELLENCE NETWORK
The OptumHealth Transplant Centers of Excellence Network features 637 transplant programs within 125 medical centers across the country.
The Transplant Centers of Excellence Network was developed by OptumHealth and the participants are evaluated on an annual basis to ensure that they continue to meet the criteria for which they were originally selected.
Over 12,000 transplant referrals are managed by OptumHealth each year, making it the nation's leading transplant management company.
THE OPTUMHEALTH PEDIATRIC TRANSPLANT CENTERS OF EXCELLENCE
OptumHealth's Pediatric Transplant Centers of Excellence Network includes 48 medical centers and 176 transplant programs.
Contracted facilities have met stringent credentialing criteria that have been developed specifically to address the complex needs of children undergoing transplantation.
THE TRANSPLANT ACCESS PROGRAM (TAP)
TAP is available for members or insureds who elect not to use the OptumHealth Transplant Centers of Excellence Network.
TAP provides geographic access and economic relief through prearranged contracts for 310 transplant programs at 95 medical centers throughout the U.S.
THE OPTUMHEALTH "NO FLOORS" NETWORK
The OptumHealth "No Floors" Network is comprised of 254 programs at 56 transplant centers across the country.
The contracts with these facilities eliminate the possibility of paying for a transplant at a percentage of billed charges.
The program's contract provisions do not include floors or stop loss provisions.
CONGENITAL HEART DISEASE (CHD) RESOURCE SERVICES
CHD Resource Services is a complement to Transplant Resource Services.
The program provides our clients' members and insureds with access to 13 of the nation's leading CHD programs.
Consulting expertise is available to help facilitate referrals.
CANCER RESOURCE SERVICES (CRS)
Through CRS, our clients' members and insureds can obtain information to help them make informed decisions about their cancer care.
The OptumHealth Cancer Centers of Excellence Network is comprised of 19 of the nation's leading cancer centers.
KIDNEY RESOURCE SERVICES (KRS)
The KRS program provides access to leading dialysis centers.
The OptumHealth Kidney Centers of Excellence Network helps assure that our clients' members and insureds receive the best and most appropriate care while reducing inpatient admissions and non-network costs.
Nurse consultants provide clinical oversight and intervention that can result in improved patient outcomes and an overall reduction in treatment costs.
SPECIALIZED PHYSICIAN REVIEW
Our customers can obtain independent, expert medical opinions regarding the appropriateness of proposed transplants for specific members.
Review services are also available in the area of congenital heart disease and complex cancers.
TRANSADVISE
OptumHealth's TransAdvise is a complimentary service for our clients who have contracts with OptumHealth.
TransAdvise clinical consultants assist our clients and their members and insureds by providing information about transplant- and cancer- related diagnoses and treatment options.
OptumHealth's dedicated team of transplant nurse experts work with more than 12,000 transplants each year.
We have a preferred vendor relationship with GlobalCare, Inc. for both "primary" network access and "out-of-network" cost containment solutions.
GlobalCare offers access to over 100 PPO networks through the U.S., an international PPO, and a 24-hours-a-day/7-days-a-week Medical Help Desk, which assists members in locating the appropriate levels of care - anywhere in the world.
GlobalCare's goals are to assist our clients' members in making informed medical decisions, provide the best cost-effective solutions and reduce overall medical costs.
National Care Network (NCN) specializes in providing medical claims payers with comprehensive, measurable and technologically advanced medical cost management services.
Data iSight is the company's new and innovative product that leverages nationally-recognized datasets and methodologies to create a peer-based comparative analysis
Payers may select pricing methodologies consistent with their goals and objectives.
Data.iSight offers pricing transparency for payers, providers and patients through a web portal.
Our claim recovery vendor, Health Decisions, Inc., is among the most comprehensive and sophisticated post-payment claim recovery services in the industry. The focus for recoveries is in the following areas:
Coordination of benefits
Medicare responsibilities (ESRD, retirees, the disabled)
As the nation's only independent cancer risk management company, ITA Partners, Inc.develops and implements proprietary strategies that lower claim costs and improve members' experience during the continuum of care. With deep expertise in oncology and insurance, ITA provides validation, access and transparency in cancer care to patients, physicians and payers. ITA sevices include:
Treatment plan validation
Education and self-care
Claims Assistance
Regular reporting
ITA Partners provides clients an average 5:1 return on investment.
Medically Complex Newborns
The Assist Group is a care consulting firm that specializes in neonatal care management, forensic audit and claims negotiation services.
CAREASSIST
Since 1999, The Assist Group has helped to ease the strain of high-risk neonatal care through its CareAssist program.
CareAssist believes that managing a neonatal case through collaborative, proactive care management results in positive outcomes for the family and significant cost containment for the health plan.
CareAssist's physician-driven care management model focuses on improving the clinical and financial outcomes of high-risk babies
The neonatal care management program has successfully reduced the length of stay by an average of 23%, with an average return on investment of 7:1.
CLINASSIST
The Assist group's ClinAssist forensic review applies medical and financial knowledge to establish fair and reasonable settlements of claims.
ClinAssist's dedicated staff of professionals uniquely reconstructs the course of care to clinically validate the care path.
A comprehensive analysis is performed to determine if the billing chronology mirrors the patient's clinical condition and if charges are consistent with medical billing standards.
Charges are reviewed for errors, such as unbundling, and to identify unnecessary therapies and experimental drugs or procedures.
Forensic review services have achieved an overall savings of 24% off of billed charges.
Ingenix is our preferred vendor for predictive modeling. Ingenix is a recognized leader in providing innovative predictive modeling and information solutions to the healthcare industry. Ingenix's products empower organizations to improve their performance at all levels.
Organizations use Ingenix's Impact Pro software suite to measure performance, predict future medical costs and identify at-risk patients, enabling targeted, proactive medical management and financial initiatives.
Impact Pro is the industry-leading predictive modeling and member identification software system that uses clinically meaningful methods to accurately measure and characterize future health risk for individuals and populations.
Organizations use Impact Pro to improve clinical quality, member satisfaction and outcomes through effective medical management and financial applications. Impact Pro is used by leading health plans and clinicians.
Advanced Medical Strategies (AMS) provides peer-to-peer collaborative physician interactions to improve quality of care and reduce healthcare claim costs. AMS contracts with over 800 specialty physicians and assists clients through:
Concurrent medical director services, which provide proactive medical case management by physician specialists to prevent costs from reaching catastrophic levels
Physician consulting for patient-specific cases to provide independent opinions regarding the appropriateness of treatment and related issues
Retrospective reviews of clinical chart documentation with medical necessity conclusions, detailed clinical summaries of hospital days reviewed, and detailed listings of denied or reduced charges as a function of medical necessity denials or alternate levels of care recommendations
Through our arrangement with Axia Strategies, our clients have access to unique programs that are designed to help them secure the most attractive and competitive PBM arrangements and to more effectively manage rising pharmacy costs. Axia can help you determine:
If your PBM's financial offerings are competitive and properly aligned with your organization's objectives
If your PBM is delivering the discounts, rebates and savings based upon your current contractual arrangement
If your benefit design and clinical initiatives are positioned to effectively manage today's rising pharmacy costs
What else you can do to manage your overall prescription drug costs
Unified Life Insurance Company provides an independent, supplemental group insurance policy to selected client groups of Catholic-sponsored health plans. The product and the Unified-health plan business arrangement have been specifically designed to provide an effective means to meet client demands and still remain compliant with the ethical directives of the Catholic Church and state insurance laws.
The supplemental policy is issued directly to each insurance group.
The scope of coverage can be packaged into any combination of family planning services at the group level.
The health plan provides only limited involvement by assisting with set-up arrangements, providing monthly eligibility files and premium collection.
