18.4.1 Medical Cost Management
Medical cost management (one of the most promising means of controlling claims expenses and plans) utilizes four general approaches: Mandatory second opinions, precertification review, ambulatory surgery, and case management.
Mandatory Second Opinions
...are necessary before an insured undergoes any form of nonlife-threatening surgery. If a second opinion is not obtained, benefits can be reduced.
Precertification Review
...is when the insured must obtain "permission" from the insurer before seeking nonlife-threatening hospital care. In case of an emergency, most plans will waive precertification if the insurer is notified within 24 hours of admission.
Ambulatory Surgery
...provides insureds with the choice of outpatient or inpatient surgery. If the insured opts for outpatient surgery instead of inpatient, some plans will offer discounts like waiving the deductible as an incentive since outpatient surgery would naturally be less expensive for the insurer.
Case Management
...is a process that may deter very expensive claims. Case Managers (CMs) are medical specialists within the insurance company who review cases that may potentially become large claims. These CMs work along with the patient to obtain the best care in the least expensive manner. The purpose of case management is to let the insurer take an active role in the management of what could potentially become a very expensive claim. When a case manager is assigned to an ongoing claim, it is called "concurrent review."
