The J.P. Farley Corporation’s Connected Care Services medical management unit has been awarded the Health Utilization Management Accreditation from URAC, a Washington DC-based health care accrediting organization that establishes quality standards for the health care industry. The URAC accreditation process demonstrates a commitment to quality services and serves as a framework to improve business processes through benchmarking organizations against nationally recognized standards.
The J.P. Farley Corporation Managed Care System focuses on increasing the quality of care, providing value added services, and controlling health care costs. This system involves teamwork between the medical professional, Preferred Provider Organizations, The J. P. Farley Corporation, and plan members. Utilization Management is a key strategy in effectively managing care and controlling costs. Nurses, nurse assistants and a Ph.D. staff our Utilization Management Team, with access to a team of doctors. The cost containment features of our system are highlighted below:
- Hospital Precertification – This process addresses the medical expenditure before it occurs. When a patient's physician determines a need for hospitalization, our medical review specialist confirms the necessity for hospitalization by evaluating the diagnosis. Concurrent Review – Prior to the scheduled discharge day, our medical review specialist contacts the admitting hospital to verify that the patient will be discharged on time. If the patient is staying longer than what has been certified, documentation of medical necessity is verified before approval.
- Retrospective Review – If a patient is admitted without being precertified, treatment and documentation is reviewed to confirm the medical necessity of hospitalization. Certification of Focused Outpatient Procedures – A list of outpatient procedures is developed with the plan sponsor. These procedures require precertification, and are evaluated by the nurses to determine if they are necessary, or if there is a need for further medical review. Mental Health and Substance Abuse Treatment Plan Review – This process requires a treatment plan that establishes duration and type of treatment. The purpose is to verify a proper diagnosis with the assistance of psychological or psychiatric testing and to assure that the mode and duration of treatment conform to the diagnosis.
- Case Management for Chronic and Large Cases – Potentially high cost cases are reviewed with the physician and other health care providers to determine the appropriate level of care. Alternative treatment programs, facilities, and equipment are researched (Home Health Care, Skilled Nursing, Hospice, Home Health Aids, etc.); discounts are negotiated. Our nurses make the arrangements for care, and also work closely with the patient, the patient's family, and the doctor to ensure that the treatment program is followed.
- Large Case Alert – If the patient's diagnosis and treatment are expected to exceed more than half of the specific insurance amount, the plan sponsor and the insurance carrier are notified. Hospital Bill Audits – Hospital bills greater than $20,000 is checked line by line to make sure the services were performed, and that they were necessary.
- Home Health Review & Fee Negotiation – Reduced hospital lengths of stay have caused a surge in the use of home health care such as infusion therapy, physical therapy, rental of durable medical equipment and home nursing. This surge has also caused a proliferation of both highly qualified and less qualified providers of these services, erratic pricing, and questionable incentives. We provide pre-treatment analysis of the appropriateness of care and negotiation of the price of care, which results in assured quality of treatment and can reduce the cost of this ever-increasing expense by 50 percent or more.