Offering a comprehensive approach to managing health care costs and care coordination for members

On average 8% of employees account for over 70% of healthcare costs in a group. Early access to Case Management can provide members with education and support to maintain and enhance their level of wellness and quality of life and to help the employers control costs.

How GuideCM Can Help:

Identify candidates for Case Management

Our Registered Nurse Case Managers use data from multiple sources to determine candidates for Case Management which include: Customer Service Phone Calls, Trigger Diagnosis Reporting, Claims Data, Pharmacy Claims Data, and Precertification Reports.

Offer comprehensive Case Management

Case Managers create a member specific plan of care and collaborate with the member to reach their personal care needs. Once a member has been identified, our Case Managers provide:

· Comprehensive Needs Assessments

· Discharge Planning

· Care Coordination

· Discussion and Coordination of Alternative Treatment and Care Settings

· Disease Specific Education

· Member Health Risk and Disease Knowledge Assessment

· Disease Knowledge Assessment

How You Benefit

Our knowledge of managed care and clinical information allows our Case Managers to interact between the patient and the payor. In order to meet quality and cost containment goals, our Case Managers provide the payor with the following benefits:

Better Member Health and Satisfaction

Your health plan members care is followed by our Case Managers who actively engage the member and their providers to ensure the best care and compliance with treatment protocols.

Cost Containment

Case Management’s goal is to make sure the member is in the proper place and level of care. This limits the plan and member cost and gets the member to the appropriate level of care.

Bundled Pricing or In-Network Providers

We have access to alternative solutions that minimize the employees out-of-pocket expense and limit the plans cost. These bundled pricing solutions give the member access to higher quality, lower cost providers.

Direct to Lower Cost Providers

Our Case Managers are able to direct members to lower cost providers or in-network providers to minimize the plan and the members cost.

Out-of-Network Claims Negotiation

Our Pre-Certification Department can determine if a provider is in or out-of-network prior to the service being rendered. This early intervention allows us to protect the member and the plan by negotiating with the provider up front for a lower rate.

Early Notification of Catastrophic/Chronic Illnesses

Pre-Certification and Case Management are the front line for identifying potentially catastrophic claims and directing the member to the best setting for care. In addition, they can help members with chronic illness more effectively manage their health and the cost to them.

Utilization Management

Our Utilization Management program is designed to ensure optimal, cost effective outcomes and maintain a focus on quality care for both inpatient and outpatient services for the provider, employer and member. We utilize nationally accepted criteria to determine medical appropriateness for service.

Our team continues to monitor the members care and communicate with health care providers so we can follow the member through the healthcare system. We monitor utilization, savings, and the impact of benefit design.

  • Pre-Certification & Pre-Determination

  • Emergent Admission Review

  • Concurrent Review

  • Retrospective Review

  • Discharge Planning

  • Case Management Identification

  • Large Case Management


Reduce Costs

On average, 20% of your enrollees will account for 80% of your overall costs. GuideCM’s Case Management was designed to mitigate the financial burden of these high-cost patients, while at the same time maintaining timely and appropriate care for patients who are seriously ill. Our Case Managers are able to reduce costs, help the patient receive the best possible care, and maintain a personal and caring approach at the same time.

Take Care Of Your Healthy Life

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