Overview of Services
 AdvoCare is a group health and
workers’ compensation
managed care organization.
AdvoCare's Workers' Compensation Managed Care Organization (MCO)
provides medical management, bill processing, and dispute resolution
services to both state-funded and self-insured employers. AdvoCare works with the injured
employee, the employer, and the provider to develop a plan for
treatment, review treatment requests, monitor the cost and quality
of care, and establish return to work goals - with careful
consideration of the needs of each participant. From the first
report of an injury through a successful return to work, we strive
to provide significant cost containment without sacrificing customer
service or optimal patient care.
AdvoCare's Group Health Division provides utilization
review, case management, and maternity management services to its
clients. Through review of the necessity, appropriateness, and
efficiency of services rendered under industry-accepted guidelines,
utilization management seeks to ensure that the patient receives the
correct level of care required. Select cases are referred to case
management based on complexity, severity, and chronicity. Maternity
management works with women throughout a pregnancy to provide
education, guidance, and identification of high risk factors.
To find out more about how the AdvoCare Advantage can
work for your company,
click
here. Workers' Compensation Managed Care
On October 20, 1993, the Ohio Legislature passed House Bill
107, initiating a series of reforms to the workers' compensation
system. These reforms included the establishment of the Health
Partnership Program (HPP), a managed care initiative for
state-funded employers. Under this program, employers select a
managed care organization (MCO) to provide medical management
services for injured worker claims.1
AdvoCare's workers' compensation MCO division has provided
medical management, bill processing, and dispute resolution
services to its employers since the HPP began in 1997. Their
functions include:
- FROI Processing
- Treatment Request Review
- Treatment Plan Development
- Medical Management
- Bill Review
- Return-to-Work Planning
- Voc. Rehab. Coordination
- Communication
1Health
Partnership Program (HPP). (n.d.). Retrieved February 23, 2006,
from http://www.ohiobwc.com/basics/guidedtour/generalinfo/ProvGlossHPP.asp Group Health
AdvoCare’s Utilization Management program is designed to manage
healthcare costs by reviewing medical services for necessity,
appropriateness, and efficiency to ensure that a patient receives
the right level of care. Our program reduces the number of
unnecessary or inappropriate healthcare services by approving
admissions and procedures, determining length of stay, and
conducting discharge verification. AdvoCare has the ability to
customize services required for authorization based on the
client’s individual benefit plan.
AdvoCare’s Case Management program utilizes registered nurses who
focus on those cases requiring an additional level of management
based on complexity, severity, and chronicity. The case managers
make the healthcare system work for both the patient and the
client by influencing and managing quality, cost, satisfaction,
and optimal health status across all healthcare settings. The
nurse case manager works in partnership with the patient and their
family, the physician, and the claims payer/TPA to facilitate and
coordinate appropriate care and services as well as
patient-centered approaches to education self care management.
Our Maternity Management Program is an early identification and
intervention program that assists mothers and babies in having a
healthy start with pregnancies, births, and newborn care. FROI Processing
First Reports of Injury (FROIs) are processed to ensure timely
submission to the Bureau of Workers' Compensation. Upon
notification, the BWC assigns a claim number, and treatment can be
rendered for the injury. Treatment Request Review
Requests for treatment of a work-related injury, along with any
supporting medical documentation, are reviewed by a nurse. Based on this information, the nurse determines if the treatment
is both necessary and appropriate for the allowed conditions on
the claim. Treatment Plan Development
In coordination with the employee and healthcare providers, a
nurse case manager will create a care plan that considers all
aspects of the employee's recovery and assists with a safe and
timely return to work. Medical Management
AdvoCare will attempt to identify claims that will involve
extensive treatment and ongoing medical management as early as
possible. As part of this process, nurse case managers will
assure that the treatment protocols are appropriate for the
injury. Both the quality and the cost of the care the
employee is receiving are monitored. Bill Review
Bills submitted to AdvoCare are reviewed according to
nationally accepted clinical editing guidelines. AdvoCare
also assists providers in submitting accurate bills for timely
payment. Return-to-Work Planning
In conjunction with the injured employee, employer, and
physician, goals are established for returning the employee to
work safely. Vocational Rehabilitation Coordination
AdvoCare will identify injured employees who may benefit from
additional services provided within a vocational rehabilitation
plan. These services include job retention, gradual return
to work, and job search assistance.
- These services are not applied to the employer's risk,
instead being covered through the surplus fund. This
protects the employer's premium rate.
- Certified Rehabilitation Counselors are utilized to attend
physician appointments with the injured employee and keep the
case on track for a timely return to work.
- Remain-at-work services can be utilized for those injured
employees that have difficulty doing their particular job.
- The number of lost days may be reduced as a result,
ultimately lowering the employer's premium.
- These services are charged to the employer's risk fund,
not the surplus fund.
Communication
Throughout the claim, AdvoCare will communicate with and
educate the injured worker, employer, and provider regarding the
claim process and treatment plan. Ongoing communication is
essential for a well coordinated, timely, and safe return to work
for the injured employee. Utilization Management
AdvoCare's utilization management program is designed to manage
healthcare costs by prospectively monitoring the use of healthcare services. This program facilitates the appropriate
provision of employee health benefits in meeting the patient’s
need for care. Utilization management includes medical, surgical,
maternity, pediatric, mental health, and chemical dependency
review services.
Decisions are based on medical necessity determination
utilizing national, industry-accepted guidelines and individual
patient clinical information. All treatment decisions remain the
responsibility of the patient and the attending physician. Utilization management also provides an opportunity for
identifying potential case management referrals for those cases
requiring a higher level of management and intervention. Case Management
AdvoCare uses a comprehensive medical management approach for
all case review. AdvoCare’s case management, as a component
of overall medical management, focuses on those cases requiring an
additional level of management because of complexity, severity,
chronicity, or use of medical resources.
AdvoCare's case management aims to:
- assist in assessing and planning for an individual’s need
for health services in a timely and cost-effective manner;
- promote quality, safe, and cost-effective care;
- minimize the fragmentation of healthcare services across
the continuum of care provider community;
- foster quality, effective, and efficient access to healthcare services;
- assist patients in achieving an optimal level of wellness
and function while empowering the patient to make informed
decisions;
- facilitate communication and collaboration with all
appropriate parties;
- assist with coordinating and implementing treatment plans
that are clinically appropriate;
- promote quality cost-effective outcomes; and
- monitor and evaluate outcomes.
Maternity Management
AdvoCare's Maternity Management Program aims to identify women
early in their pregnancy in order to increase awareness of
pregnancy-related health issues. Targeted educational materials
are provided to participants as appropriate. This program also
seeks to support the pregnant women in making healthy choices for
themselves and their babies during their pregnancy, and to
identify women with high risk factors earlier in the pregnancy to
better manage and reduce the incidence of preterm labor and
preterm birth. |
