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Complex Care

Complex Care

One percent of your employee population may experience and live with a severe life-altering health condition.

Our experienced Case Management team promotes quality of life outcomes and significant savings by focusing on patient advocacy, navigation assistance, early intervention, care coordination and resource management. Specialty case managers have expertise in specific diagnoses such as transplants, cancer, rehabilitation and high-risk maternity.

Case Managers

Only experienced registered nurses carry the Certified Case Manager (CCM) designation. Working with patients and caregivers to complement a doctor’s prescribed plan of care, our Case Managers help with everything from condition management, specialty pharmacy management, sub-acute levels of care transitions, coordination of home health care and equipment needs, and side effect management to financial and community resource assistance.

Specialty case management is a part of the Complex Case Management program at no additional charge. These specialty case managers are CCMs with specific clinical expertise in the area of need. They work closely with Centers of Excellence (COE) programs and guide members to the appropriate facilities based on favorable health outcomes and lower claim costs.

Specialty case management is required for:

  • Organ and bone marrow transplant
  • Dialysis
  • Oncology
  • Rehabilitation from spinal cord injuries, strokes and traumatic brain injuries
  • High-risk maternity

Advocacy and Care Coordination

Our Certified Case Managers are a resource for both patients and caregivers. They arrange patient care and negotiate cost-effective rates for services, therapies and equipment if an in-network provider isn’t available. In addition, case managers assist members in finding and obtaining community services and provide education on topics such as managing pain, proper nutrition and possible medication side effects or interactions.

Specialty Rx Management

Our Pharmacy Benefits Management team includes nurses and pharmacists who focus on the clinical management of specialty medications such as patient education and monitoring, medication adherence assessments, proactive side effect management and even injection training. Due to the expensive nature of specialty drugs, MedCost also works to identify cost-effective funding opportunities to ensure medication adherence is met.

Effective Specialty Rx Management at Work

Harvoni, a medication for Hepatitis C, costs an average $32,114 for a four-week supply.* Members who take this treatment appropriately can avoid liver complications or a possible liver transplant that can cost $200,000 on average. However, the drug requires strict adherence and must be taken every day at the same time. Pharmacists and nurses reach out to counsel members on adherence, side effects and dosing/administration of their treatment regimen. The team is available 24/7/365 should members have a question. They also schedule refills to prevent gaps in care.

*International Federation of Health Plans

Telehealth Services

Telehealth services, including consultations by phone, apps or videoconferencing, are on the rise as employers make medical care more accessible, affordable and convenient for their busy employees. Many acute health concerns can be treated without incurring the expense of an office visit, urgent care facility or emergency room visit. Conditions such as respiratory and urinary tract infections, allergies, anxiety, muscle and arthritic pain, and minor joint sprains and strains can all be treated via phone or mobile device. Employees have 24/7/365 access to doctors licensed to practice medicine in their respective states. A Caregiver Program also allows employees to add an elderly or sick relative to their account and arrange video or phone visits for a flat fee. Telehealth can be added to your health plan at any time.

Behavioral Health

Those employees with higher usage rates of medical services, such as those with complex health conditions, typically have a higher prevalence of depression and anxiety disorders. MedCost nurses routinely conduct depression screenings as part of our Personal Care Management, Complex Case Management and SmartStarts Maternity Management programs. Intensive case management for emotional and behavioral health issues is provided to address these needs and ensure that members continue to have ongoing support.