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Talk More – Deny Less

October 2016 Blog, Health Management, The Business of Health Care Comments Off on Talk More – Deny Less

What defines an effective patient management vendor? Is it working in a delegated relationship and issuing denials of inpatient days? How about refusing to approve services that might be helpful in moving a patient out of the hospital to home? Maybe making adverse determinations without discussions with medical care providers?

At ProgenyHealth, we don’t believe that any of those things produce effective or sustainable relationships with providers. Instead, we promote proactive and consistent dialogue with our clients’ providers to anticipate clinical needs and prepare for the next level of care. Our nurses and physicians speak directly with the clinicians in the facilities to discuss the care being provided, barriers to patient progress, and anticipated discharge needs. They discuss the best approach to achieving a healthy outcome and, where possible, address discharge needs early. This proactive and consistent dialogue is one of the primary tenets of the ProgenyHealth medical management model.

In addition to the active clinical dialogue, we work to engage the parents/caregivers early to provide education and support. Our goal is to make them knowledgeable so that they will be comfortable with taking their babies home, as soon as they are medically prepared for discharge. What’s more, our data shows that the readmission rate for these babies is lower than our clients’ baseline readmission rates, even with the shorter NICU stays! We know that a large part of this successful statistic is due to our dedicated case managers providing ongoing support for the entire first year of the baby’s life. Having a trusted, consistent source for information and medical advice is a powerful tool to help avoid unnecessary Emergency Department use and subsequent hospital readmissions.

Our clients consistently experience at least a two to three-day reduction in their average NICU length of stay, year after year. But those reductions are rarely from denials of inpatient days. In fact, ProgenyHealth denies less than 1% of requested hospital days. Instead of denying days, we develop working relationships with the NICU providers, and discuss what is best for the NICU patient. Additionally, our Nurse Case Managers and Social Workers reach out to the family while the infant is in the hospital to educate them and begin planning for a safe discharge.

Our unique, industry-leading approach to managing a fragile, resource-intensive, medically complex neonatal population makes a big difference to our patients, their families and the insurers we serve.

What are you looking for when you evaluate a medical management vendor?

About Our Author:

Dr. Steven Richardson is the Chief Medical Officer at ProgenyHealth. He oversees our clinical operation and is responsible for the improvement of the medical services and outcomes we provide to our client’s most fragile members.

Dr. Richardson, a Board Certified Physician in Preventive Medicine, has over fourteen years of experience working in multiple payer organizations including Aetna, Prudential, and United Healthcare, holding various leadership positions, including Lead Medical Director and CMO. Prior to joining ProgenyHealth, Dr. Richardson was the Medical Director at a medical management company that ran one of the country’s largest Medicare ACO’s.