Coordinating members’ Care – One Case at a Time

The personal touch supplied by Medicus Resource Management is most evident through the work of the individual Case Manager. Unlike other utilization resource companies, Medicus includes case management services in its low monthly fee. Using nationally recognized case management techniques, the registered nurse/case manager assumes the following major responsibilities:

• Works with stop/loss carriers to assure they are aware of current treatments and member progress
• Investigates pertinent medical history, present illness, and the current, preferred course of medical care for a specific condition
• Works directly with referring physicians after a members needs have been determined to secure services within the designated network of providers
• Locates facilities for appropriate care and negotiates fees in the event that network providers are not available
• Follows members throughout the continuum of care, including inpatient stays, physician care, ancillary services, and pharmaceutical needs.

Typically, members who may benefit from case management services are identified using several key sources, including hospital admission notifications, stop/loss reports, and precertification. Members with any of the following conditions are reviewed for case management services:

• AIDS/HIV
• Asthma
• Burns (severe)
• CAD (Coronary Artery Disease - requiring more than one intervention)
• Diabetes (uncontrolled)
• Multiple trauma
• Oncology
• Outlier Days (more than five-day length of stay)
• High-risk obstetrical cases
• Preterm newborns/NICU admission
• Stroke
• Consult case manager
• Hepatitis C
• Transplants
• Chronic renal failure
• Cystic fibrosis
• Multiple sclerosis
• ALS (Lou Gehrig's Disease)
• Cardiomyopathy
• Readmissions (more than one admit in three-month period)
• Head trauma
• Spinal cord injuries
• Congenital anomalies
• Out of network (outside of tertiary)

Playing a Key Role

The Case Manager plays an important part in planning a members discharge, and acts as mediator with insurance carriers and/or employers. The Medicus Case Manager maintains contact with the member to coordinate care and provide both the member and family with support, both during treatment and after. Finally, the Case Manager encourages the attending physician to stay in touch with both Medicus and the member throughout the course of treatment in order to initiate care management activities.