One way Sentinel helps manage healthcare costs and achieve optimal outcome is through our Utilization Management (UM) program. This type of savings is generated through monitoring healthcare services and providing early intervention. Sentinel’s UM service is very cost effective and has flexible options.

Precertification

Sentinel’s UM process begins with a simple phone call. We encourage patient participation and recommend that they make the initial contact. This enables our reviewers to obtain important information about the patient’s condition and existing support network. If medical review is being performed by the member's PPO Network (such as Cigna) - demographic information is obtained with the call transferred as appropriate for further review determination.

Our review team will then examine procedures and proposed admissions to confirm the need for hospitalization and, when appropriate, assign an initial length of stay. While evaluating medical needs and appropriateness of care or treatment, our reviewers aggressively consider all available options and will often make suggestions for alternative, cost-effective care. This is done using standardized medical criteria guidelines (see sMed Policies) with input from our Medical Director.

Other major components of the precertification phase include:

• Second opinions – will be requested according to clients’ specifications on particular surgical procedures or treatment—although all elective surgery may be subject to second opinions.
• Emergency admissions – all emergency admissions are reviewed and assessed to validate the need for the emergency care. This review is usually completed within 24 to 48 hours after admission.
• Preferred provider management – reviewers will verify whether or not a provider is affiliated with the patient’s benefit plan. Patients are informed of the provider’s plan participation in order to make appropriate selections that may affect his/her benefits.

Concurrent Review

During the course of treatment, Sentinel monitors a patient’s care and progress by maintaining regular communication with his/her physician. In cases involving hospitalization, reviews are conducted every 2 to 3 days to determine whether the patient is a candidate for early discharge or requires extended stay due to complications.

Discharge Planning

Sentinel reviewers are very involved with the coordination of a patient’s extended and home healthcare needs following discharge from the hospital or facility. Typically, discharge planning begins with Sentinel’s first patient contact and continues throughout the patient’s stay.

Whenever possible, the provider and patient are encouraged to consider in-network providers and alternative healthcare options. Using alternatives can eliminate the need for an in-patient stay, or shorten the length of stay. Considering alternative services to hospitalization provides an uncompromised cost-effective level of care.

The following services are available as stand alone products or may be purchased in conjunction with basic UM Services and offer opportunities for additional cost savings:

Outpatient Medical Review

In combination with Sentinel’s comprehensive inpatient Utilization Management, the following outpatient review programs are also available:

Outpatient Services and Treatment Review

Clients establish specific outpatient and diagnostic procedures as the focus of Sentinel's review for medical necessity and appropriateness. Clients can choose from as little as 3 or 4 commonly over-utilized outpatient procedures or elect unlimited determinations to be made on all outpatient diagnostic and/or surgical treatments.

Outpatient Therapy Review

• All types of therapy may be included such as physical, occupational, vision, speech, dialysis, radiation, hyperbaric oxygen, cardiac, pulmonary, respiratory, phototherapy, plasmaphoresis, etc. Therapy review also includes IV infusion such as chemotherapy.
• Reviews ascertain whether the service and any modalities are appropriate.

Home Health Care, DME and Injectables Review

• Home health care services – skilled nursing, physical and occupational therapies are closely monitored for appropriateness and medical necessity.
• Durable Medical Equipment (DME) typically for items over $1,000 or rental items is reviewed for medical necessity.
• Injectable drugs can be extremely costly and are reviewed following FDA approval guidelines as well as stringent medical criteria.

Fees for outpatient review services vary.

Retrospective Review

• Sentinel evaluates claims per client request for services which have already occurred to determine medical necessity and appropriateness of care.
• All medical documentation is requested in order to provide a comprehensive review with written recommendations to the client

Internal and external peer review

• Sentinel offers an internal physician peer review service by employing a combined review approach from a RN, administrator and Medical Physician. Reviews are initiated by clients to answer very specific questions regarding a particular case. Internal peer review charges are from $150 - $425 per review.
• As required by regulation, Sentinel facilitates a 3 tier external review process using contracted independent review organizations (IROs) for final external review decisions to be made on behalf of benefit plans. Costs are variable and based on reviewer specialty and extent of documentation.

Case Management

• Throughout the steps of the UM program, certain patients are identified and recommended for case management in addition to being identified through an automatic report scan of all precertifications for specific diagnoses.
• Case managers evaluate the patient's needs, monitoring the appropriateness of both care and cost, explore alternative modes of care if necessary, and stay in continuous contact with the patient, family and provider for the duration of the case.
• Individualized monthly reports are generated for the client which include treatment notes, patient progress updates, and projected outcomes and costs.
• Case management fees are fixed charge rates for the initial and subsequent months of a patient's case based on a very reasonable hourly rate. Sentinel has eliminated “unknown” costs for our clients by first eliminating the request per hour and approval process saving the client’s time and then offering comprehensive service at an affordable fixed cost.

Medical Bill Auditing

Despite efforts in the healthcare industry to correct billing problems, reports confirm that many medical bills still contain errors. Fortunately, Sentinel is here to help.

Medical bill auditing can be included in the basic UM program fee or can be billed separately. Sentinel's auditors' thoroughly examine provider bills for inaccurate entries, as well as ensure that services are not excessive or unnecessary. They also check to see if actual invoiced amounts are in-line with usual customary and reasonable charges. Discrepancies are identified and recommendations are made in writing to the client. In a recent 2 year analysis of audits performed, 14% of billed charges were identified as errors, not medically necessary or improperly billed.

Invoice Processing

Sentinel's extensive UM and auditing experience, coupled with a state-of-the-art computer system has enabled us to expand our portfolio of services to include claim pre-pricing, pending or as we call it - Invoice Processing. This highly computerized service is performed by a dedicated staff of professionals utilizing advanced data management and reporting capabilities.

• Sentinel personnel process invoices based on a PPO's fee schedule or simply key in all data to create an electronic claim for processing.
• Claims are received, input and redistributed as quickly as possible in order to facilitate faster review by claims administrators and payment to providers.
• Electronic claims are accepted through Emdeon® while paper claims are sent via standard USPS.
• Processed claims are transmitted through FTP in standard 837 format, or dropped to paper.
• The key to Sentinel’s success in this process is the personal attention given to every claim which is verified and input by trained professionals with a 99% accuracy rate on data input.
• Meaningful, easy-to-interpret reports are distributed in accordance with client requests.
• Sentinel is also including National Correct Coding Initiative edits to further enhance the savings generated for clients.

Call for details.

Provider Charge Negotiation

For clients who request negotiation of charges in cases where PPO access is not available:

• Sentinel contacts the provider to negotiate using preferred provider reimbursement if available or Medicare reimbursement as a negotiating reference.
• In some cases, negotiated rates are already in place through Sentinel's previously established provider contracts.
• The main purpose of negotiation is to reduce costs and confirm the provider will not balance bill the patient usually in return for prompt payment by the client within 10 - 15 days after confirmed agreement.
• The negotiation process is most successful with hospitals and ancillary providers (such as DME providers and Home Health Agencies).
• All information is communicated in written format to clients including Sentinel’s fee for negotiation.
• Fees are charged at 10% of savings if contractual arrangement is in place or 15% of savings for direct negotiation.

DRG Review/ UCR Calculation

For clients who have plans that reduce for out of network according to Medicare reimbursement or for payers who have no obligation to provide other than minimal payment to providers (i.e. County, State or Federal Correctional facilities) – Sentinel is excited to offer Medicare reimbursement calculation for providers billing:

• Inpatient (Diagnostic Related Group – DRG) – hospital specific.
• Outpatient (Ambulatory Surgery Center - ASC and Outpatient Prospective Payment System – OPPS) – national and regional specific.
• Dialysis (End Stage Renal Disease – ESRD).
• Physician Charges – national and regional specific.

This service works in conjunction with Sentinel's medical audit review. Each bill is first reviewed for proper billing in compliance with National Correct Coding Initiative edits and reduced accordingly. Then the bill is recalculated based on Medicare reimbursement. Clients then may render payment based on the entire recalculated amount or a percentage.

Cost for this service is the greater of 1% of savings or $15 per claim.