MEDICAL MANAGEMENT MATTERS
Medical Management Matters
BY : DEBORAH AULT , RN , CCM , CCP , AATMC , MBA PRESIDENT – AIMM ( AULT INTERNATIONAL
MEDICAL MANAGEMENT ) “ NURSE DEB ”
There are numerous significant benefits for employers to move their health benefit offerings into the self-funded arena , and the fine folks at Qandun are well-versed to go through those with you . However , the move is not entirely without challenges . As business owners , C-suite executives , and others with a vested interest in the overall well-being of a company begin to look at self-funding as an option , they often begin to ask some very pertinent questions : Are we healthy enough to consider self-funding ? Is the timing right to make the move to self-funding ? Can we get stop-loss coverage that is fairly priced ?
These are absolutely the right considerations to have . The problem , however , is that fully insured health plans — and the carriers that you purchase them from — are extremely protective of the data you would need to be able to answer those questions . In the past , what happened was that decision makers had to take a bit of a “ leap of faith ” in order to jump from fully insured to self-funded . Fortunately , the typical outcome was a positive one , but as with anything , there was the occasional bad experience . Let ’ s face it — nobody wants to be “ that guy ” who took the leap to self-funding only to be hit two or three months in with the delivery of premature triplets ! It is especially frustrating when that catastrophic event was absolutely foreseeable .
Another “ old fashioned ” approach was to have employees complete health questionnaires . It does get some data , but it ’ s all self-reported data , and you get everything on the spectrum from the hypochondriac who takes this as an opportunity to tell you about every minuscule cough / cold / sniffle to someone newly diagnosed with cancer who doesn ’ t want anybody to know so the employee fails to complete the form ( or to complete it accurately ).
Now there is a solution for employers who are poised to consider self-funding as an option and who are asking the right questions but are having difficulty getting the information . We developed a product called the Bridge Program . It is an adjunct employee benefit offering . It absolutely does not interfere with or disrupt your current fully insured plan at all . In fact , it enhances your members ’ experience with their health plan . Let me explain .
First , this product gives your health plan members 24 / 7 access to a professional nurse who has advanced expertise at helping them to navigate both the health care delivery system and their health plan . They now have a concierge to hold their hand through a health event . Someone to help them be as healthy as possible , as quickly , efficiently , and effectively as possible .
Secondly , it provides an online Health Risk Assessment survey that looks both at current conditions and future health risks . It gives the patient a meaningful and insightful report to take back to his or her doctor as a health conversation starter and health risk mitigation stimulator .
Third , it ensures , via the “ Happy Birthday Health Drive ,” that outreach to every member of your plan occurs . There ’ s no better time to tell your employees that you care about them , and you want them to be healthy , than around their birthday . It ’ s also a great time for people to take stock of their overall health and to ensure that they are doing their part to stay healthy for the future years to come . We engage the members of the plan conversationally , making sure they have an appropriate primary care physician relationship ; informing them of what a good head-to-toe annual physical should include for someone of their age , gender , and lifestyle ; and assessing their current health issues or concerns .
All of these interactions give us a large data set from which we can then answer the following questions : Are we healthy enough to be self-funded ? Is now the right time to switch to self-funded ? And it also gives us the clinical information needed for solid clinical underwriting of the plan — helping you get that fair and reasonably priced stop-loss or join that captive you really want to be in . It ’ s no longer a mostly blind leap of faith . Now you ’ ve got actual clinical underwriting — all handled by an independent , outside clinical agency — protecting you from HIPAA risk !
Once a group becomes self-funded , its opportunities explode ! As fun as that can be , it also brings its own unique set of challenges . It ’ s imperative that these first tender years of being self-funded get handled with special loving care ! Often I see groups make the conversion to self-funded in an unmeasured and haphazard way , and they ultimately suffer the consequences for that .
Here ’ s what I mean : a self-funded group has a great deal of autonomy in terms of coverages , premiums , specialty products , and the like that did not exist when it was fully insured . One potential weak point creeps in when the group fails to engage the right advisor to assist them during these important formative years . The right advisor will get to intimately know the self-funded health plan sponsor — its culture , its motivation behind offering health benefits , its population , and the things that are unique to the group . That advisor will then take responsibility for identifying which vendors the group should consider to deliver the critical elements of its health plan .
This is crucial . If the advisor does not take the time to truly understand the goals , objectives , and tolerances of the group , then it ’ s unlikely that the advisor will select the
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