Med-Cert provides its clients with Health Care Management, which encompasses intervention
prior to, during, and after the event through such services as Disease Management,
Utilization Review, Case Management, Transplant Network Access, and Retrospective
Claims and Case Review. Each program is self-contained yet interactive, thus, providing
comprehensive care management which focuses on the entire continuum of care and
wellness/illness. Elements include client/patient education, advocacy, empowerment,
assisting clients/patients in making informed decisions. Med-Cert is staffed by
fully trained and experienced professionals with both specialized and general expertise. Programs,
though designed around nationally-accepted and approved protocols, are flexible
to the needs of the client, whether self-funded or fully-insured.
Precertification and Continued Stay Review: The activities of Med-Cert's Utilization Management department include:
Med-Cert has developed written policies
and procedures including specific formats typically completed throughout the review
process. Timetables to be met, protocols for review, decision-making and appeal/reconsideration
standards are always upheld during the review process. Licensed Registered Nurses
and/or Physicians do all reviews and reconsiderations involving medical data. Reviews
are performed telephonically and procedures in all cases comply with the requirements
of the client's health insurance policy or benefit plan. Med-Cert provides a toll-free
number accessible 24 hours per day. Normal hours of operation are from 8:00 a.m. to
5:30 p.m. Monday through Friday (except holidays). All incoming calls are either
answered or routed to an answering service. A Med-Cert review nurse will respond
to all messages within one business day. The Utilization Management department works
closely with all other Med-Cert departments, the employer group, TPA and MGU to
assure that the patient is receiving the highest quality, most appropriate, and
most cost effective services possible.
- Inpatient and Outpatient Preadmission Review
- Admission Review
- Discharge Planning
- Retrospective Review
- Readmission Review
Maternity Management: Our
Healthy Beginnings maternity management program provides books,
pamphlets and other information to expecting mothers.
Health Information Nurse: Med-Cert
offers a toll-free number to access a Health Information Nurse. This "Ask A Nurse"
type program consists of general health and wellness topics provided telephonically
to the plan participant.
Case Management Services
Large Case Management (LCM): Med-Cert's
certified Case Managers are responsible for the management of catastrophic illness
and injury cases. The goals are:
Implementation of LCM will assure quality of care, maximize recovery, minimize complications,
and permit decision making by the payer and by the plan participant, optimize benefit
allocation, minimize future claims, and decrease disability time.
- the assurance of quality of care,
- the assurance
of quality of life and
- the promotion of the appropriate use of health care resources.
Wellness and Disease Management (WDM):
The goal of our WDM program is to better educate a person about their actual or
potential disease state so that they may be empowered through knowledge to appropriately
manage their own health, thereby decreasing over-utilization and increasing appropriate
utilization of resources. The program is focused on education and empowerment through
individual teaching of Proactive Health Management Skills by appropriate resources
and through support to encourage compliance and use of learned skills.
Transplant Coordination: A special
Transplant Registered Nurse Case Manager coordinates benefits, plan design, carrier
programs, networks and preferred providers, care (before, during and after the
transplant), appropriate use of pharmacy plans, negotiation of levels of care and
fees, and community resources. Med-Cert works with the patient and family, Transplant
Surgeons, Immunologists, Medical Directors, Transplant Coordinators, Facility Financial
Counselors, Home Care Providers, etc. to improve care, cost, communication, and