To be effective, medical management practices need to define a clear vision of the overall wellness and cost goals of the program and to develop tactics that enable the achievement of those goals. Processes must be put in place to select the proper vendor, provider and product design to realize the vision, and to create robust internal and external reporting mechanisms to gauge the success of the strategy.
How we can help you
PricewaterhouseCoopers can help payers identify short- and long-term opportunities to improve the effectiveness and efficiency of a medical management organization and position it for the future.
We use a variety of methodologies to identify medical management improvement opportunities:
- Medical management strategy through implementation
- Review of existing documentation, including policy and procedure manuals, training manuals, job descriptions, and staff and unit productivity reports
- Work observations with in-house client staff, including non-clinical support staff, prior authorization and telephonic concurrent review nurses, case managers, disease management nurses and physicians
- Rounds with onsite nurses in hospitals, observing the chart-review process and interactions with hospital case managers, discharge planners, physicians, members and their families
- Work distribution analysis
- Process flow analysis
- Future state visioning, including innovation analysis and collaborative design
- Action planning
