How can we improve both Utilization Review and Provider Network performance using e-Ordering with CDS?

In the managed care and medical cost containment worlds, the time and point-of-order are usually the starting point of everything — the ‘head of the snake’ as it were. The opportunity to capture, filter (for ‘appropriateness’), authorize and direct orders and referrals to optimal service providers is paramount in managing other ‘downstream’ patient care, medical expense and insurance benefits.

The advent of secure, web-based applications and platform solutions presents the stakeholders involved with patient treatment and recovery with the tools to efficiently process the myriad transactions involved with managed care requirements while the patient is at the order physician office. With the advent of cloud-based and integrated ordering, decision support and provider network tools, point- and time-of-order medical and referral management can now be fully realized.

Ordering Performance is critical

Medical ordering and referral coordination in managed care programs is a highly interdependent, rules-driven, multi-party process that can be confusing, challenging and expensive for all stakeholders. Patient care and claims administration are routinely burdened by archaic, manual approaches to ordering that rely on paper documents and telephonic exchange.

At the center of most clinical and benefit decisions, timely care coordination and information delivery related to testing, treatment and other specialist services is critical to medical outcomes and overall costs – yet acutely impacted by administrative functions, intermediaries and under-performing systems. Service levels, throughput and expense can be immediately improved when medical ordering and managed care tasks are accomplished using intelligent online solutions.

Timely and ‘appropriate’ ordering positively impacts patient care, outcomes and costs at all levels.

In many markets – like workers compensation, property & casualty, auto and employer self-insurance – ordering clinical and other patient services in managed care systems and PPOs is still predominated by inefficient paperwork, manual processes, fax transmissions and phone communications, with occasional use of outmoded web-based forms. Here, medical ‘necessity’ review, pre-authorization and referral coordination of medical orders is typically handled by insurance claims administrators and third party agents operating remotely from the treating physician and/or ordering specialist, and ‘downstream’ from the time-of-order and point-of-care.

Especially in such fragmented industries, risk management scenarios and time-sensitive situations, the ability to quickly and accurately determine and adjudicate medical ordering ‘appropriateness’ levels (i.e., at the time of order) — and further to align and coordinate all necessary stakeholders, while not encumbering others — brings vast improvements in both utilization management and cost containment efficiency, effectiveness and returns.

e-Ordering’ – electronic ordering software that operates in conjunction with intelligent, high performance workflows and decision support tools, medical guidelines, and rules-driven referral processing – is proven, preferred and widely regarded as an optimal approach in realizing the next levels of managed care performance and returns.

The evolutionary ProviderBASE® Platform and Solution Set offers a re-engineered and elevated e-Ordering and Care Coordination approach, especially to underserved payer, indemnity and healthcare markets — one that is a “game changer” for the insurance, managed care and provider industries:  a ‘win-win-win‘ for all stakeholders.

ProviderBASE delivers secure online e-Ordering with embedded clinical decision support (CDS), expert, evidence-based guidelines, and payer-defined rule sets integrated within advanced Medical Management and Provider Network tools — removing complexities and aiding physicians, claims adjusters and care managers in quickly making better value-based decisions for their patients and injured employees.

ProviderBASE helps provider groups, insurers, administrators and MCOs timely connect ‘appropriate’ orders and optimally-guided referrals to the right PPOs, vendors, specialists, facilities and suppliers … bringing new levels of performance to the medical utilization management, pre-certification and care coordination processes.

Right order, right time, right place, right cost

  • Entirely cloud-based – access from any connected device

  • On-demand clinical guidelines  –  for quick, easy and accurate reference

  • Diagnosis-driven Decision Support – via clinical guidelines and payer rule sets

  • Real-time Reporting – order ‘appropriateness’ scoring, order status, notices, analytics

  • UR/Medical Review ‘Triage’  – order capture with first-pass + filtering and direction

  • Automated Authorization  – per payer rules; coding and routing to stakeholders

  • Optimized Provider Selection & Referrals  – via Network PPO and/or direct to provider

  • Online Patient Concierge  – for scheduling, instruction, reminders, confirmation, and more

  • Interface Clinical & Business Data  – EMR/EHR, UR/UM, bill review, PMS, billing, claims, QA and more

ProviderBASE® has the Solution.

ProviderBASE is a Network-vendor management and Ordering platform with clinical decision supported and rules-driven optimization, which delivers new levels of automation, performance and program returns via online tools made available at the time-of-order and point-of-care.

ProviderBASE is inclusive and agnostic – and can engage initially with either the Network or the Client/Payer/MCO – which latter may use any or all of 1.) Network-vendor, 2.) direct-to-provider or 3.)  hybrid models.

Medical Management