Health Benefits

Care Navigation and Advocacy

Members don’t have to go it alone

The healthcare system can be a source of anxiety for many people. Faced with this reality, we believe that creating smarter, more informed and empowered healthcare consumers boosts population health and reduces healthcare costs for everyone.
Members don’t have to go it alone

Healthcare Management

Real savings, real caring. We see our in-house, fully-integrated healthcare management team as a way we can help deliver substantial savings for our clients while providing expert help, advocacy, and support for their members when they need it most.

Our team includes dozens of nurses, covering 70+ subspecialties and decades of medical experience, each one coming to work every day with a dedication to helping members.

Watch our video to learn more about our approach to healthcare management. 

Utilization Management

We want to make sure members get the right care at the right time, and that their care doesn’t cost them—or their employers—more than it should.

Our URAC-accredited utilization management solution reviews medical necessity and appropriate use of healthcare services and facilities to determine whether benefits are payable under the health benefit plan.

Program nurses also review all certification requests against evidence-based best practices and care-planning tools provided by Milliman. When necessary, the program team uses independent physician peer reviews with specialty care providers.

Individual Case Management

Sometimes when faced with a significant illness, members and their loved ones need help making informed decisions about care. Our case management program can help take the burden off their shoulders while also controlling costs for members and employers.

Our case management program is a collaborative process that ensures members get medically necessary care in an appropriate, cost-effective setting by assisting members and their caregivers in making informed decisions based on their needs and health plan benefits.

Consumer Advocacy with Connect

Our Connect program includes access to a benefit specialist and a registered nurse advocate to help relieve the stress of complicated benefit and clinical issues. Connect offers members:
  • Clinical guidance and advocacy
  • Cost-effective utilization guidance
  • Benefit program optimization support

Clinical Guidance with MyNurse 24/7

The URAC-accredited MyNurse 24/7 is a member’s first resource for immediate clinical guidance on everyday health issues. In addition to helping members avoid unnecessary and costly trips to the doctor or ER, MyNurse’s registered nurses may identify emerging conditions before they become more serious.

The nurses can engage members in nearly 150 languages over the telephone and through live chat to help improve their health, provide health information, and assist members in their healthcare decision-making processes based on recognized clinical guidelines and national standards of care.

YourCARE Health & Wellness Program

YourCARE combines population health management, focused disease management, and chronic condition monitoring into one comprehensive health and wellness program.

To help members get and stay healthy, avoid gaps in care, and manage their healthcare costs, the program includes:
  • A health risk assessment
  • Optional biometric screenings
  • Preventive reminders
  • Outreach to high-risk members who have not yet incurred a serious illness
  • Incentive tracking
  • Health advice and guidance

Digital Savings Solution

The Digital Savings Solution (DSS) is an innovative marriage of consumer-centered telemedicine, telebehavioral health, cost and quality transparency tools, and regular, targeted member outreach designed to help save employers and members money. DSS not only gives members the tools they need to get the cost-saving care they need, it also makes sure they know how to use those tools and encourages utilization throughout the year.

We believe that the DSS is such a game-changer that we backed it with an ROI guarantee. If employers don’t save more than they pay, we’ll credit the difference.1

Watch our DSS video to learn more.

 

Telemedicine

With just a few taps, telemedicine provides members with 24/7 on-demand digital medical doctor visits for common conditions like:
  • Sinusitis
  • Upper respiratory infections
  • Bronchitis
  • Urinary tract infections
  • And more
When a board-certified physician is just a phone call away and an expensive, stressful trip to the ER is the alternative, telemedicine is really a no-brainer.

Cost & Quality Transparency

We believe in equipping members with the tools they need to become smart, savvy healthcare consumers who make cost-effective decisions about their healthcare. Our cost and quality transparency solution allows members to quickly and easily compare quality scores for healthcare facilities and find the fair price for a particular procedure or test. Members can then ask their doctor to refer them to a quality, cost-effective facility that saves money without sacrificing care.

Cancer Management & Support

Through our cancer management and support program, we assign an oncology nurse to provide patients with an individual care management plan. The nurse is a resource to caregivers and provides the patient and his or her family with support that helps them navigate the maze of providers and appointments that are typical during cancer treatment.

This kind of support is not just good for cancer patients and their families, it’s also key in helping to control costs for members and employers alike by reducing detrimental and costly gaps in care. Our clients experienced a total program ROI of 14.1 to 1.2

Maternal & Neonatal Health

Given the risks to children and the associated costs, it’s critically important that women who are expecting know all they can about their health to help ensure a full-term pregnancy and a healthy delivery. Our comprehensive maternal and neonatal health solution helps promote the health of each eligible soon-to-be mom and a full-term healthy delivery, along with controlling healthcare costs without compromising maternal and neonatal care.

Other Products and Services

In addition to our claims and benefits administration expertise, we have a number of other solutions. Take a look: