Medical Management

inVentiv Medical Management focuses on promoting
the right care at the right cost in the right setting.

As part of our comprehensive portfolio inVentive Medical Management provides a variety of healthcare medical management review services that promote adherence to evidence-based medicine, support delivery in the most cost-effective care setting, and are designed to reduce the likelihood of care that is unnecessary or unsafe.

  • Medical Necessity Determinations are a prospective, concurrent or retrospective review of treatment by an inVentive Medical Management physician to determine if the treatment is reasonable and necessary for the diagnosis or treatment of illness or injury or to improve function under the provisions of the applicable health benefits plan.

  • iProcert ™ Utilization Review Services utilizes a physician directed group of inVentive Medical Management Registered Nurses to evaluate the medical necessity, appropriateness and efficiency of the use of health care services, procedures and facilities.

  • Case Management is a collaborative process of assessment, planning, facilitation, care coordination, evaluation and advocacy. Case management engages with patients and their caregivers to provide educational support to families and identify resources to improve overall care.

Empowering patients to become active participants in their healthcare, rather than passive recipients.

 

Seal-CM-HUM

Cost Management

It's More Than Just PPO Discounts!!!

The inVentiv Medical Management cost management solution combines the strength of their health care forensics with the power of technology. They combined industry leading administrative code edit surveillance with their own customized clinical surveillance rules based on their physician logic and subject matter expertise. Further, they have the proven ability to build and leverage provider relationships to achieve greater negotiations and consistent performance.

The inFinite Platform features pre-adjudicated clinical and financial audits designed to ensure members receive quality care that is aligned with iMM’s mission of most appropriate care, at the most appropriate cost with a goal of best in class outcomes.

The infinite Platform provides complete integration of claims surveillance, clinical edits, predictive modeling, case management, wellness, disease management and network re-pricing built for group level customization with client portal access.

Claims Surveillance
Real-time, continuous surveillance of claims identifies the appropriate strategies for clinical and financial impact. Utilizing physician logic, the inFinite Platform continuously builds a robust utilization history and identifies members for care management opportunities.

Claims Code Editing
Our claims code editing system automatically checks each claim for errors, duplicated, omissions and suspect coding relationships by referencing the data against an expansive database. Administrative and clinical edits are configurable based on group specifics and plan language.

Clinical Audit
After claims are identified for intervention, they are triaged by a Clinical Nurse Auditor for initial review then sent to a Physician based on claim complexity and specialty when necessary. Provider issues are minimized by leveraging the credibility of our Physicians for Peer-to-Peer discussions about care.

Negotiations
Professional Negotiators can address savings for cost containment for in or out-of-network claims and often achieve greater reductions than PPO discounts. We achieve 100% signed negotiations with the provider to avoid the risk of balance billing to the member.

 

 

PREFERRED HEALTH PLAN OF THE CAROLINAS
PO BOX 220397 CHARLOTTE, NC  28222
LOCAL: 704.847.2321     Toll Free: 866.636.0239     FAX: 704.847.3014