Reason to outsourceFiled Under: Health Economics

Should You Leverage a Specialized Partner?

Reason to outsource

Six reasons to let experts manage your NICU Care Management

Health plans increasingly outsource processes and programs to specialized partners to improve care, streamline administrative processes, establish accreditation credentials, and expand access to care coordination. Year over year, business process outsourcing by health plans has grown 22 percent.1

Payers deciding which programs are best handled by dedicated specialists must weigh a range of factors in their decision, including the costs, time, talent, management, oversight, and other resources that must be enlisted to build an in-house solution. Because of the time lost, payers must also consider the opportunities missed in their endeavor.

Building an in-house NICU Care Management program requires a high level of accrued knowledge – people knowledge, data knowledge, and technology knowledge – knowledge that cannot be quickly hired. For this reason, payers frequently outsource NICU Utilization Management (UM) and Case Management (CM) services. When reviewing outsourced services, payers must evaluate their core competencies and the stress on in-house resources to deliver a critical-skill program like NICU.

When deciding to enlist a specialist partner, health plans should consider these six factors:

The Unique Challenge of NICU

High-volume specialties like radiology, oncology, or post-acute care offer a strong case for building in-house management capabilities. In comparison, NICU claims make up a relatively small percentage of a plan’s total claim volume. The complicating factor is that NICU claims consistently represent the top 1% of costs. An additional problem is that NICU cases tend to be very complex, which makes UM and CM critical to improving NICU outcomes and reducing costs.

Because of NICU cases’ complex, demanding, and specialized nature, these cases cannot be handled efficiently by existing UM and CM programs. They require high-touch care management solutions, coupled with data intelligence and clinical best practices to improve health outcomes and reduce the cost of care.

Domain Expertise

Health plans looking at building a NICU care management program should plan on making a significant investment in domain expertise. The NICU team needs experience in improving quality and efficiencies, driving effectiveness, and delivering impacts on member health and utilization outcomes coupled with data capabilities to leverage predictive analytics. Career expertise in clinical settings must be augmented with ongoing education.

When evaluating organization competencies, health plans discover that their core functions lean more toward clinical quality, sales, marketing, and member experience – more so than clinical specializations. For this reason, the competitive market and the ever-shifting demands of compliance compel payers to focus on their core functions and outsource the rest.

This trend is particularly pronounced in the self-insurance market, where the cost and complexity of specialization and compliance drive employers toward working with a partner specialist.


A low-volume specialty like NICU doesn’t always warrant making significant investments in the workflow systems that high-volume specialties like radiology, cardiology, and cancer require for caseload efficiency. Accurate analytics alone require large caseloads of data.

Like any specialty, NICU demands dedicated tools for real-time predictive modeling, NICU-specific EHR, workflow automation, UM analytics, payment integrity, and integrated case management. Without sufficient case volume, health plans are hard-pressed to justify the infrastructure or specialists needed to impact NICU health outcomes and total cost of care.

Specialized Case Management

Health plans use case managers to ensure that patient care is clinically appropriate, efficient, and effective. NICU case managers do this and more. Engagement with mothers and families is the most critical activity of all. Immediately upon admission to the NICU and throughout the first year of life, engagement helps newborn caregivers become educated and empowered. NICU case managers also assist with discharge planning, screen mothers for postpartum depression, assess social determinants of health (SDoH), and help families solve other impediments to an infant’s health and well-being.

At-risk infants and their caregivers are less likely to achieve healthy outcomes if their basic needs are not met. NICU case management requires dedicated workflows and geo-mapping tools to identify and solve issues like opioid addiction, food insecurity, domestic violence, housing, and other needs the baby may have. Because babies’ needs are 24/7 in the weeks and months after discharge, NICU case managers must be available around-the-clock to answer questions and coordinate care.

Time Investment

Building the infrastructure and fielding an experienced team takes time. For this reason, developing an accredited program can take up to 12 months or more. The program also requires annual checks and recertification. The NICU-specific CM and UM knowledge to build a program are unlikely to be available in-house, so hiring that expertise takes time. And once a program is operational, accreditation, certification, and compliance can take months or years for full implementation.

The Cost Equation

The bottom-line question to ask before bringing in a specialized team: will the program deliver quantifiable, consistent cost savings? Many plans already have robust and innovative UM/CM programs serving their member populations. However, with NICU driving nearly half of a health plan’s infant hospitalization cost, a focused solution is still needed.

ProgenyHealth delivers cost savings with an ROI of 2:1 or better by impacting the variables that affect quality and cost outcomes the most. These include:

  • Leveling of care during NICU stays
  • Reducing unplanned hospital readmission and unnecessary ER visits
  • Ensuring payment validation and integrity for NICU claims
  • Assessing and solving the social determinants of health
  • Delivering a predictable ROI from focused UM/CM services

A Dedicated Solution Optimizes Savings

At ProgenyHealth, NICU Care Management is all we do – hundreds of thousands of NICU cases to-date – more than most plans see in several decades. Consider the savings:

  • ProgenyHealth’s approach reduces readmission rates by up to 50%. In a study of 3,529 non-Progeny and 1,312 Progeny commercial NICU babies in the same market, our solution helped drive a 71% reduction in ER visits.
  • With the typical NICU length-of-stay (ALOS) at around 20 days, we consistently bring ALOS down – stays that are 3.5 days shorter on average.
  • Our Payment Validation & Assurance program helps prevent inaccurate payments and delivers maximum value from UM/CM services, while identifying billing errors and anomalies that drive up NICU claims costs.

At the Heart – a Proprietary Platform

Our proprietary platform, Baby Trax®, uses real-time predictive and prescriptive analytics drawn from the hundreds of thousands of NICU cases to implement over 20 years of best practices in medically complex infant care. The technology creates a digital footprint of the patient’s journey to prompt the NICU team at each decision point. Predictive analytics and diagnostic triggers drive structured yet individually tailored care management plans. The result is seamless care coordination, compliance, and analytics that inform action and manage utilization.

An in-house UM program cannot duplicate ProgenyHealth’s proprietary platform. For health plans, TPAs, ASOs, and self-insured employers, outsourcing to a dedicated partner like ProgenyHealth can expand your NICU Utilization Management and Case Management capabilities, reduce your cost of care and deliver a solid business case ROI.

  1. Black Book’s survey 5,400 health plan BPO users collected from Q3 2014 to Q1 2015