Ensuring The Right Care In The Right Setting
MedCost performs aggressive inpatient management nationwide, by balancing quality patient care with safety and cost-effectiveness. Our experienced team of registered nurses, under the supervision of our Medical Director, uses evidence-based, nationally recognized guidelines to evaluate appropriate standards of care and treatment. MedCost also maintains a review panel of more than 70 physician consultants who are board certified and currently practicing in a wide variety of specialties.
Care That Begins Before And Extends Beyond The Hospital Stay
Members’ health is a top priority, so before any member is admitted to the hospital, MedCost should be notified for pre-certification.
Our nurses will perform a pre-admission review to make sure that hospitalization occurs only when medically necessary and in the most cost-effective setting.
Once a member is admitted, the nurses conduct a concurrent review to monitor the quality of care received and determine the medical necessity of each continued day of hospitalization.
While a member is still in the hospital, our nurses take a proactive approach to transitional care by communicating with doctors and hospital staff to anticipate any needs the member may have after discharge, such as rehabilitation or home health services, and locate the best possible in-network source. The nurses also negotiate discounted rates for prescriptions, equipment, or services that fall outside a member’s health plan. This work is done behind the scenes so members can enjoy a smooth and comfortable transition home (or to another facility for less acute care) and focus on recuperation.
A retrospective review of medical records also can occur after the member has already received medical treatment to ensure that the care provided was medically appropriate for the condition. This type of review is used when required pre-certification does not occur, such as in emergency situations. Since the review takes place before any payment is made to the provider or hospital, the health plan can use the results to approve or deny coverage.
Member Education For Certain Complex Procedures
For certain procedures, the MedCost nursing staff offers pre-operative and post-discharge counseling
to educate the member about the treatment plan, confirm that planned services are in place and follow-up appointments have been made, and to make sure that the member understands the recovery process and the importance of medication adherence. This level of support for a member’s transitional care helps to reduce readmission rates. More targeted transitional care counseling is available as part of our health coaching
program for conditions with a high likelihood for readmission, such as COPD, asthma, diabetes, heart attack and/or irregular heartbeat, and high blood pressure.
Accredited By URAC
The MedCost Utilization Management program is URAC accredited, which assures members and clients of our compliance to federal and state standards for review procedures. URAC is a well-known, independent organization that validates a company’s accountability and commitment to quality.