Your employees. Their health plan. Our business.

Medical Management

Medical Management

This is the most effective tool that we use to help improve your bottom line. Statistically, Gateway Health Alliance clients experienced an average of 16% reductions in utilization in their first year with us. That translates directly to savings for everyone on the plan. We can prove high quality care and real savings. When compared with our largest competitor's utilization statistics, Gateway had 23.1% fewer admissions and 22.5% fewer inpatient hospital days.

Our Approach

Our approach encompasses Disease Management, Case Management and Utilization Review – all aimed at improving members’ quality of life, while preventing or controlling unnecessary utilization. Working closely under Medical Director, Michael Caplan, M.D., Gateway nurses provide inpatient and outpatient utilization review that produces lower utilization rates than Virginia’s largest health plan.

New advanced Disease Management techniques help control the significant costs incurred on employees with chronic illnesses such as diabetes, cancer, asthma, congestive heart disease, hypertension and high-risk maternity. Healthy Solutions by Gateway Health Alliance, Inc.SM uses the latest technology to pair nurses with members one-on-one in improving lives, managing risks and optimizing the provider/member relationship.


Affirmative Statement

Gateway Health employees make clinical decisions regarding health care based on the most appropriate care and service available. We do not reward providers or other employees for any denials of service. We also do not encourage nor reward clinical decisions that result in decreased services.

In addition, Gateway Health does not use incentives to encourage barriers to care and service. We prohibit any employee or representative of Gateway Health from making decisions regarding hiring, promotions, or termination of providers or other individuals based upon the likelihood or perceived likelihood that the individual or group will support or tend to support the denial of benefits.


Physician Directed

No one knows the medical needs of patients better than the physicians and nurses who treat them. Gateway’s Medical Management committee is made up of practicing physicians and nurses. Their intimate knowledge of resources and practice patterns facilitates efficiency and responsiveness in every phase of a patient’s treatment plan.


URAC Accredited

Utilization Review Accreditation Commission/ URAC is a nationally recognized non-profit, quality improvement leader that reviews and audits a broad array of health care service functions and systems. URAC standards promote evidence-based practice, collaborative relationships with providers, consumer education and shared-decision making with consumers. These standards apply to all types of organizations providing services for individuals with chronic illnesses, including health plans, stand-alone disease management organizations and medical management organizations.