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Medical Management

Medical Management for Employers

Overview

Through the proactive use of internal medical management services, we apply proven standards for efficient and effective care. Gateway settings assure a patient receives no more or no less than the condition requires, keeping costs low and quality of care exceptionally high.

This is the cornerstone of Gateway’s Managed Care programs. The greatest long-term savings will be achieved by lowering utilization of high-cost medical services and steering employees to high quality health care providers.

Gateway’s Medical Management Department is supervised by Monica Crews, MSN, RN, Director of Medical Management Programs at Gateway Health, and clinically directed by our Medical Director, Dr. Michael A. Caplan, MD (Board Certified in Internal Medicine). Our program is nationally accredited by the Utilization Review Accreditation Commission (URAC), as well as, the Commonwealth of Virginia and adheres to stringent NCQA standards. 

The Medical Management Committee advises the staff and reviews all applicable policies, procedures, and appeals by members or providers. 

 

"We applaud Gateway Health on achieving URAC Health Utilization Management Accreditation," said URAC President and CEO Kylanne Green.  

"In today's healthcare market, URAC accreditation provides a mark of distinction for organizations to demonstrate their committment to quality healthcare."

 

 

Utilization Review

Pre-authorization (Inpatient and Outpatient Services). During the pre-certification process, members or physicians register future procedures or surgeries with Gateway nursing staff under the direct supervision of our Medical Director. This gives us the opportunity to explore alternatives related to the particular procedure, whether length of stay, location or cost re-negotiation. Furthermore, early knowledge of a procedure allows us to better direct care and to send educational materials that are extremely helpful to the patient and family members. Denials are authorized only by the Medical Director.

Concurrent Inpatient Review. Following each pre-certification, our medical department performs a review to determine that a patient’s treatment is received as outlined by the physician and agreed as medically indicated by our Medical Director. Active monitoring and thorough evaluation of a patient’s length of stay, change in diagnosis, and treatment progress ensures necessary and appropriate healthcare, while avoiding unnecessary expenses when a hospital confinement or a surgical procedure is proposed. Utilization reports can be generated in terms of diagnosis codes, reasons for non-payment, COB savings, providers, individuals/divisions, dollar amounts, etc.

Case Management

This essentially can be divided into two areas: catastrophic case management and episode management. Both are extremely cost effective for our clients. After determining potentially high cost, high utilization cases through in-house analysis of usage data, Gateway’s medically trained team assesses a situation then coordinates, monitors, and evaluates options and services. Quality, cost effective outcomes are achieved by meeting an individual’s health needs. Evidence of cost savings resulting from our case management is demonstrated through our customized reporting.