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Care Management
All managed care organizations strive to deliver quality healthcare while controlling costs. In this sense, Triad Healthcare, Inc. is no different than many others. Often, however, it is the cost that is used to determine the value of the program and quality health care delivery can suffer. Quality measures are often created after cost measures are ensured, resulting in "quality" that can be as much "rationalization" as it is "reality." Rationalized quality may offer a pleasing, annual, bottom line, but real quality offers this with the additional benefit of member satisfaction. Satisfied members and their employers offers the opportunity for many pleasant annual bottom lines. Our Care Management programs are focused around member and employer satisfaction. We place a legitimate emphasis on education across those stakeholders who are important to our clients: the patient, the employer and the provider.
Prospective, Retrospective and Concurrent Review
Healthcare providers determine what medical services are rendered and why. This role should not be controlled by the development of policies and rules that do not allow adequate latitude to provide the best care for the patient. Our position is that it is best to manage care by managing the provider and not profession. To do this, we manage each member's care with the treating provider, individually.
Triad Healthcare, Inc. offers a full range of operational services that support its unique medical management philosophy. We manage cases based on clinical necessity following specific criteria which includes:
- Nature, severity and complexity of complaints
- Duration of symptoms
- Numerical Pain Rating Scale
- A Proprietary Severity Matrix and Functional Index
- Collection of clinical data thru initial and continuing care forms for both in and out of network provider services
- Establish, maintain and apply medical necessity criteria as a basis for evaluating care
- Automation of authorizations
- Outcomes and quality review
Certification and extension of patient care is based on clinical necessity, objective documentation of recovery and patient outcomes
Member and Provider Education
Triad Healthcare, Inc. is dedicated to providing high-quality, cost-effective customer service to meet the needs of patients, plan sponsors and providers. Training of all Customer Service representatives is conducted on an on-going basis. Member and provider services can be tailored to fit with the health plan's philosophy concerning the optimal level of interaction between its members and its "carve-out" vendors. Triad Healthcare, Inc. representatives educate members and providers about specialty care and address any questions and concerns. Our call center uses on-line inquiry systems, imaging technology and a contact management system to support both members and providers.
These services include:
- Toll-free call center services for Member and Provider inquiries
- Referrals to network provider.
- Member appeal initiation, tracking and resolution
- Member benefit and plan eligibility verification
- Member communication regarding UM and appeal issues-telephonic and written
- Provider communication of UM decision explanations - telephonic and written
- A program designed to allow patients to discuss their care with Triad Healthcare, Inc. Physicians when a determination of current course of care may not appear to be medically necessary.
- Annual member satisfaction survey
Broker and Customer Education
Triad Healthcare, Inc. representatives educate providers and members about the program, assist providers and members with claims status and utilization management inquiries, resolve problems, and initiate appeals where appropriate. Our account managers serve as primary point of contact to client organizations and plan sponsors. The level of interaction that our customer service has with client plan participants or members varies based on the health plan's customer service philosophy concerning "carve- out" vendors. We work with each carrier to optimize the level of service to providers and members to make sure it is cost-effective for both organizations and clear to the member.
Medical Policy Development
Triad Healthcare, Inc. has created a comprehensive medical policy development program intended to optimize the relationship between the vendor, client and provider.
We have accomplished this through:
- Professional, Consensus Driven Policy Development (QIC)
- Real-time data feeds
- Employing Practicing Providers - all providers employed by Triad Healthcare, Inc. are required to practice a minimum of 20 hours per week in the field
- Literature Review
- URAC Accreditation
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