Managed Care

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Managed Care

Overview and Levels of Managed Care
Preferred Provider Organization
Shared Savings Program
Cost Reduction and Savings Program
Utilization Review and Management
Case Management
Managed Pharmacy
Employee Assistance Program
Organ Transplant Networks
Mental Health and Substance Abuse
Bill Review

Overview
Employers are looking to add the advantages of managed care programs and specialty products to further reduce the cost of providing quality health care benefits to employees. Fiserv Health satisfies the fundamental needs of self-funded employers by delivering comprehensive administration services and stop loss insurance coverage.

Fiserv Health has critically evaluated the full spectrum of managed care services available across the entire health care industry and has established strategic partnerships with key vendors who can provide services complimenting our product offerings. As a product integrator, we have the resources to coordinate virtually any combination of products and services, including employers’ existing vendor relationships. This translates into multiple choices for employers. Best of all, these managed care services are fully linked to Fiserv Health's administration system and may be bundled or unbundled as needed.

The key to success for any managed care program is the ability to communicate plan benefits and processes to the employee. Fiserv Health can assist in preparing a comprehensive benefits communication package in support of any managed care plan we administer.

Preferred Provider Organization
A Preferred Provider Organization (PPO) is an organization of medical providers delivering health care on a discounted, fee-for-service basis. PPOs are one of the most flexible forms of managed care, providing savings and allowing the employee the option of receiving care from any provider. With a PPO, employees have a choice of using in-network providers at lower costs or out-of-network providers for increased co-payments, deductibles and coinsurance charges. If services are received from an in-network provider, both the employee and the employer can realize substantial discounts.

Fiserv Health has contracts with national, regional, and local PPO networks that can serve the needs of employers with both single and multiple locations. In fact, we have access to virtually any provider that a customer may choose to use.

Shared Savings Program
Fiserv Health's Shared Savings Program (SSP) provides a managed care solution to rising health care costs. Participants can receive discounts in standard hospital and ancillary facility charges, with or without a primary network in place. The SSP goes beyond Utilization Management in offering discounts that can result in lower out-of-pocket expenses and savings — savings that typically range from 5% to 15%. Fiserv Health’s SSP is provided by United Payors & United Providers, a national network that includes more than 6,000 hospitals.

Print the Shared Savings Program Summary

Cost Reduction and Savings Program
Fiserv Health provides its Cost Reduction and Savings Program (the “CRS Program”) as a standard part of its claims administration services. All Plan Sponsors receiving administration services from Fiserv Health participate in and receive benefits under the CRS Program.

The CRS Program has been designed to reduce costs on out-of-network claims and to seek recovery opportunities not typically included in the standard claims administration process. Participation in the CRS Program will provide your Plan with access to potential discounted charges and negotiated discounts on out-of-network claims, and potential recoveries on over-collections by health care providers.

The CRS Program is yet another way for Fiserv Health to help you address your rising health care costs. Please contact your Account Manager if you have any questions about this program.

Utilization Review and Management
To be effective, Utilization Management must do a great deal more than screen hospital admissions. The pre-admission process must be reinforced with significant knowledge of medical advances as well as an awareness of medical abuses that drive up the costs of providing heath care.

Utilization Management saves money through the Precertification of hospital stays, specified surgical and diagnostic procedures; Concurrent Review of patient care during treatment in a hospital; Discharge Planning that achieves maximum care at home or alternatively at another cost-effective facility; and Maternity Review for pregnancies.

Fiserv Health maintains relationships with selected national and regional Utilization Management firms that can provide managed care support through cost efficient efforts. Fiserv Health also offers our own Utilization review and Case Management Solution for Third Party Administrators. See your Fiserv Health representative for more information.

Print the Medical Management Summary

Case Management
Catastrophic cases, such as head and back injuries or those involving AIDS, account for only 3% of all employee benefit claims. Yet these cases account for 40% of all benefit expenses. Identifying and managing these high-risk, catastrophic and potentially high-cost claims is critical to effective medical cost management. It helps ensure that medical care for potentially large cases is appropriate under the terms of the plan from the start, and helps avoid unnecessary expense.

Fiserv Health has access to some of the best Case Management services in the industry. When combined with Utilization Management, Case Management can identify potentially high-cost cases and begin managing them as early as the first day that associated claims have been incurred.

Contact your Fiserv Health representative to learn more about Fiserv Health’s case management program. Fiserv Health’s case management strategy targets those cases requiring more attention, resulting in better medical outcomes for patients and greater cost savings for plan sponsors.

Managed Pharmacy
Prescription drugs are the fastest growing health care expenditure, representing between 8% and 30% of total health care costs. Fiserv Health has partnered with the nations leading managed pharmacy vendors to offer a program of fully integrated services designed to maximize the savings on prescription drug expenses. These programs provide access to extensive retail pharmacy networks, mail order services, and sophisticated claims adjudication systems.

The blend of national purchasing power, wholesale pricing, efficient dispensing, and maximum generic substitution enables these pharmacy programs to provide convenient delivery of quality pharmaceuticals at the lowest possible cost.

Employee Assistance Program (EAP)
EAPs are designed to assist employees, their family members, and employers in finding solutions for workplace and personal problems. Services may include assistance for family/marital concerns, legal or financial problems, elder care, childcare, substance abuse, emotional/stress issues and other daily living concerns. Among the issues EAPs may address are violence in the workplace, sexual harassment, dealing with troubled employees, transition in the workplace and other events that increase the rate of absenteeism, employee turnover, or lower productivity. The EAP addresses issues that affect employee morale or an employer’s productivity or financial success. EAPs also can provide the voluntary or mandatory access to behavioral health benefits through an integrated behavioral health program.

Organ Transplant Networks
The number and cost of organ and tissue transplant cases continue to increase dramatically each year. In fact, first year transplant costs typically range from $100,000 to $1.3 million. For self-funded employers, this represents one of the most challenging and costly health care services they will encounter.

Through industry-leading transplant networks, Fiserv Health offers a managed care transplant strategy that can reduce costs, while providing access to some of the best networks and facilities available for transplant procedures anywhere in the United States.

Mental Health and Substance Abuse
Claims-related to mental health and substance abuse now account for a significant portion of all health care expenses. In fact, stress-related work disorders, divorce, and family and child-care issues account for most visits to physicians as well as most on-the-job accidents, and the majority of health care costs stem from preventable or behavior-related causes. Unfortunately, most employers’ benefit plans focus primarily on treating physical injuries and illnesses that have already materialized.

Fiserv Health offers managed mental health services that strive to reduce cost and improve the quality of mental health and substance abuse benefits through an extensive national network of practitioners and facilities.

Bill Review
Third-party review of medical bills for excessive or inappropriate charges.