Case Management/Utilization Review ACS has established an extensive system of criteria so that potentially large claims are recognized early. ACS then begins a review of the case and determines needs in terms of managed care. Teams of registered nurses negotiate pricing, contact on-site managers, ensure that the physician's plans of treatment are being administered correctly, and monitor billing. Our case managers and claims examiners know the Plan's benefits and requirements and provide an invaluable coordination of these requirements with the health care providers.
Medical Case Management - ACS reviews ongoing health care for (a) medical necessity, (b) whether such care was reasonable and customary as to both amount and necessity, and (c) whether or not care was provided in the most appropriate medical environment. To the extent possible, such care is reviewed in advance to avoid disallowance of charges and to ensure efficient processing of claims while avoiding delays. ACS communicates the Plan's requirements to the providers in the initial stages of care. ACS never intrudes in the care of the participant; instead, ACS ensures the care is meeting such participant's needs as well as the requirements of the Plan. This ultimately means more efficient care for participants and a net reduction in costs to the Plan.
Retrospective Utilization Review - Retrospective utilization reviews are conducted to ensure that the services provided were necessary to the care and treatments were reasonable and customary both as to the amount paid and the appropriateness of the care. The results of the review are then reported to the providers. Appropriate steps are taken to mediate discrepancies so that balance billing of the participant is prevented.
Hospital Bill Audits - ACS has established criteria to screen hospital bills for potential billing problems. ACS has audit histories of the facilities from whom it has received claims and consistently updates these histories. All hospital bills are screened and charges are scrutinized. If the bill necessitates, an audit is conducted and ACS monitors the process closely to protect the Plan benefits and to avoid unnecessary costs to the Plan.
Hospital Pre-Admission Certification, Concurrent Review and Discharge Planning - Using nationally published guidelines for inpatient confinements, the Precertification Department monitors hospital admissions for medical necessity and benefit utilization. Concurrent review of hospital admissions ensures the patient is receiving treatment that is medically necessary and rendered in the appropriate setting. The Precertification area works closely with case management to provide appropriate alternative levels of care to inpatient admission when applicable and coordination of patient needs after discharge.
Maternity Care Management - The "ACS Great Expectations Program" is available to employers as an additional facet of managed care and is specifically designed to monitor the progress of expectant mothers. Early identification and intervention in high risk obstetrical situations reduces the possibility of a pre-term delivery.
Home© ACS Benefit Services, Inc. [Updated 12/01/2001]