A Pocket Guide to Medical Management

Unnecessary procedures, extraneous testing and gratuitous medications — three things that not only upset your group members, but also dramatically increase your healthcare costs.

Sadly, you both may be footing the bill for medical services that members simply don’t need. You want what’s best for their well-being and your bottom line. So how do you cut back on costs without stepping in the way of care?

The short answer: medical management.

Let’s take a closer look at what medical management actually means, why it’s important, and what it can do to benefit you and your members.

What is medical management?

Medical management is all about offering the right care, at the right price, at the right time.

In other words, no more duplicate or needless services tacked on to medical bills. With medical management, you can rest assured that your members are making the most of their health plan benefits while also optimizing costs.

Think about it like this: Every time a member files a claim, it’s a bill you need to pay. And with chronic health conditions on the rise, more Americans are filing claims than ever before. In fact, the Centers for Disease Control estimates that at least 90% of healthcare expenditures are for people with a chronic condition. According to PwC, someone with a complex chronic condition and mental illness could cost an employer 12 times more per year than a healthy employee.

To make matters worse, American healthcare costs have been rising for decades. U.S. healthcare spending surpassed $4.3 trillion in 2021 and is expected to reach nearly $6.8 trillion by 2030. As an employer, that’s a tough pill to swallow. Luckily, that’s where medical management comes into play.

The benefits of medical management

Medical management teams act as your third-party advocate, going to bat on your behalf to make sure members are getting the care they need at the most appropriate price. You get a more cost-efficient health plan experience that also offers the quality care your members deserve.

Overall, medical management can help you:

• Lower healthcare costs: Through wellness programs, review processes and other strategies, medical management can help reduce the frequency of illnesses or injuries and cut back on extraneous medical expenses.
• Improve health outcomes: More than cost-efficiency, medical management also benefits member well-being by improving access to quality care, creating personalized treatment plans, and better managing health conditions through education, coaching and guidance.
• Enhance benefit packages: Offer employees more than the standard health plan. Medical management provides value-added services and a level of 1:1 support that can take group membership to the next level.

How does medical management work?

Medical management can be broken down into four key areas:

1. Utilization management

This area of medical management involves evaluating and monitoring the use of medical services and resources to ensure they are appropriate. In short, utilization management aims to deliver the right care at the right time by promoting only medically necessary procedures, thereby reducing expenses.

This normally includes a three-step process:

• Prior authorization: Services and treatments are evaluated beforehand to ensure they are truly necessary.
• Concurrent review: Providers deliver updates on the care provided to the member when in a facility such as a hospital or rehab center, at which point nurse case managers review the services and intervene if any are deemed inappropriate.
• Retrospective review: Once treatment is complete, nurse case managers perform a clinical analysis and identify opportunities for improvement.

2. Cost containment

Medical management also includes cost containment, which aims to validate claims and ensure that services are being billed appropriately.

Unfortunately, it’s not uncommon for healthcare providers to excessively upcharge members far beyond what’s standard. For example, when one of your members undergoes outpatient surgery, you may receive a claim exceeding your expectations. In cases like this, medical management teams can step in and renegotiate the bill to a total much more appropriate for the care provided.

3. Population health management

Population health management involves analyzing medical claims to identify at-risk individuals and predict their annual cost of care. Then the medical management team develops a personalized plan to improve the member’s well-being.

These plans can include a variety of wellness programs that emphasize preventive and proactive interventions rather than reactive responses to health issues. These measures not only benefit members by encouraging them to live healthier lifestyles but can also reduce overall healthcare costs. For example, fewer hospital stays and emergency room visits translate into fewer claims, thereby lowering costs.

4. Nurse Case management

Some members, such as those with chronic illnesses and other complex conditions, may need the support of a much more high-touch, individualized medical management experience.

In these circumstances, highly trained nurse case managers can work directly with members to better understand their medical needs and help them navigate their healthcare journey. As a more personalized approach to medical management, members gain a direct line to someone who can discuss treatment options, make recommendations, and provide trusted advice on any healthcare topic.

MagnaCare: Providing the best care at the lowest cost

Rising healthcare expenses are significantly costing your business. Worse yet, the more that members access your health plan, the bigger the tab you have to pay. If only there was a way to give your members the care they deserve and still cut costs across the board.

Luckily, there is. With MagnaCare’s medical management program, you can maximize savings and deliver a better, smoother healthcare experience.

MagnaCare members benefit from not only our utilization, population health, cost containment and case management services, but also 24/7 clinical support via our nurse triage line. Our teams are fully committed to connecting your members with the most appropriate — and affordable — healthcare solutions. The result? Smarter, better, faster and more efficient care every step of the way.

Learn more about MagnaCare Medical Management today.