Care Management

Secure Health trusts our Medical Management programs and services will fully meet your group’s needs and exceeding your cost containment expectations while producing better health outcomes for your members.

As a community focused TPA, we generate quality outcomes for members and significant savings for plans by strategically keeping care close to home. This supported by the strength of your local health system, ensures quality care for employees, and saves you money on claims.

Every aspect of our Medical Management suite of programs has been carefully selected to ensure the best in customer care, cost containment, and access to quality healthcare.

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Medical Management Solutions

Secure Health provides turnkey medical management solutions powered by MedCost that generate true, direct-to-employer savings and effective care outcomes for members.

Solutions We Offer:

  • Utilization Management (Inpatient and Outpatient Review)
  • Complex Case Management
  • Personal Care Management
  • Behavioral Health
  • SmartStarts Maternity Management
  • Chronic Disease Education

Our Offerings Include

Utilization Management

We offer a URAC accredited program that balances quality patient care with safety and cost-effectiveness to ensure the right care, at the right time, in the right setting. It evaluates medical necessity of treatment and setting appropriateness for care using evidence-based, nationally recognized guidelines.

Inpatient Review

Our inpatient review program reduces days of care per 1,000 consistently below the industry average while maintaining a high level of patient satisfaction.

  • Experienced nurses provide utilization review and recommendations
  • If a member is hospitalized, a concurrent review monitors the quality of care received and determines the medical necessity of each continued day of hospitalization
  • Proactive discharge planning anticipates discharge needs during the hospital stay to reduce readmissions

Outpatient Review

Our outpatient review service focuses on high cost, highly utilized scans such as MRI, CT, and PET scans. Our goal is to reduce the number of unnecessary surgical and diagnostic procedures while keeping the member’s health and safety top priority.

  • Costs are controlled by evaluating the medical necessity of outpatient services with a three-day turnaround time for standard non-urgent reviews
  • Our qualified staff ensured that more conservative care measures have been exhausted
  • Program can be customized to meet the client’s needs

Complex Case Management

Our Complex Case Management program is designed to facilitate care for members with catastrophic illnesses requiring multifaceted care. Members appropriate for this program will have ongoing healthcare needs that can change in frequency and duration and be in and out of the hospital for various issues and requiring multiple providers and services.

Services include:

  • Condition education
  • Benefit plan assistance with arranging for services (i.e., home health, durable medical equipment, hospice, etc.)
  • Research services for experimental/investigational treatment options
  • Assist with alternate funding sources
  • Comprehensive care team collaboration to close care gaps and prevent avoidable utilization
  • Coordinate with claims, reinsurance, compliance, and regulatory needs as appropriate

Personal Care Management

Personal Care Management (PCM) is our disease management program designed to drive positive outcomes for at-risk and rising-risk members by offering comprehensive proactive methods for improving overall health. Our nurse coaches are trained in motivational interviewing, a collaborative conversation method that strengthens a person’s own motivation and commitment to change.

Most prevalent chronic conditions include:

  • Diabetes
  • High blood pressure
  • High cholesterol
  • COPD
  • Asthma
  • Congestive heart failure
  • Coronary heart disease
  • Chronic kidney disease
  • Obesity

Behavioral Health

Our Behavioral Health program guides members through the healthcare continuum from wellness and multiple levels of acute and intermediate care to case management of complex cases. The program provides cost-saving medical necessity review of intermediate behavioral health services including residential treatment, partial hospitalization, and intensive outpatient treatment.
Our staff works with the patients to eliminate barriers and encourage treatment compliance, leading to better health outcomes and significant savings.

Program objectives:

  • Assist behavioral health members through the healthcare continuum
  • Reduce inappropriate admissions and ensure appropriate levels of care are rendered
  • Proactively manage barriers to treatment and encourage treatment compliance
  • Provide additional support to promote behavioral health wellness

SmartStarts Maternity Management

The SmartStarts Maternity Management program focuses on educating and mentoring expectant mothers through each trimester. It is designed to minimize costs and health risks associated with complicated pregnancies and premature births through early risk identification.

SmartStarts provides:

  • Early identification of potentially costly and high-risk pregnancies
  • Experienced prenatal nursing staff, including certified case managers, an ASPO certified Lamaze instructor, and a certified grief counselor
  • Proactive case management of high-risk participants from a certified case manager nurse specialist
  • Decrease in pre-term and complicated birth, delivering improved maternal and infant health as well as reduced costs for the employer

Chronic Disease Education

To help groups close gaps in care, we provide educational mailers for members for targeted and diagnosed chronic conditions. Education includes information related to key labs and interventions needed to better manage those conditions.

Conditions include:

  • Asthma
  • High cholesterol
  • High blood pressure
  • Chronic low back pain
  • Congestive heart failure
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)
  • Migraines