BAC - Care Management

Care Management

BAC’s in-house nurses make the difference!

The cards and thank-you notes from BAC members displayed at our nurses’ desks capture the heart of our mission.

Example 1
Example 2

A BAC plan member was inpatient and due to be released on a Friday but was going to need an exceptional amount of care at home. The only family available to act as caregivers were the member’s parents who were in their eighties with health issues of their own. The BAC team worked to find a rehab facility so the patient could receive the needed care while having additional time to heal. Doing so prevented a very likely weekend admission to the emergency room. This did not fit the mold of ‘cookbook’ medicine; however, the patient needed more care and while the rehab stay was a cost to the plan, it saved an additional pricey inpatient stay.

Sadly, a member passed away. Our network partner for that client group approved a hospital stay for an additional two days past the date of death. The network did not want to update the patient’s expiration date based on word from BAC. They wanted to hear from the hospital before making the correction. BAC received the facility claim and our nurses reviewed the itemization. We discovered they were billing for charges to maintain life to harvest organs. Information from the hospital and network would have led us to believe the patient’s date of death was two days later so that additional charges would be covered by the plan. Clinical review led to a proper denial of incorrectly billed charges.

Download a Sample BAC Large Claim Management Report
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Improved member care and outcomes

In-house care management is integral to how BAC operates. For employees and their families this means calling one phone number for help. Our team does not need to tell a member to call the XYZ Case Management company for assistance. Often when a health event occurs, there are multiple doctors, home health care, and other rehabilitation professionals providing care. Communication becomes a problem, and a recommendation that is made might not lead to a good outcome for the patient. BAC’s nurses help guide and get all players on the same page. We will suggest optional care if we feel it will lead to a better patient outcome.

Searching out the missing puzzle piece

If diagnosis and treatment do not seem to align, or we need more information to understand the member’s medical scenario, BAC proactively reaches out to providers to collect clinical information. In the case the provider’s office is not communicating, our nurses will reach out to the patient to gain insight and see how we can help. Obtaining clinical information is key to seeing the whole picture of a patient’s health journey. It also aids in BAC’s relationship with carriers, both from an underwriting perspective at renewal time and we stay in open communication throughout the year to help stop loss claims get reimbursed quickly.

Pivotal in the underwriting process with carriers

Between our nurses and the wealth of underwriting knowledge in our sales and marketing team, BAC can have impactful conversations with stop loss carriers on what the real risk outlook will be for the coming year. This makes a remarkable difference in proposed rate increases. We can drill down and provide specific details on treatments and cost estimates.

Integrated pharmacy data

BAC makes sure that data from our Pharmacy Benefit Managers (PBMs) is fully integrated into our systems. We are loading prescription claims daily so the BAC team can see at a quick glance what drugs are being filled. We can intervene faster on high costs drugs, ensure accumulators are linked with the pharmacies to prevent excess member out-of-pocket costs, and spot trends. We are not reliant on calls to the PBM to get information.

Claims specialists and nurses working hand-in-hand

Nurses and Claims Specialists unified on the same team adds meaningful value for our members. Our Claim Specialists are skilled in understanding the details of a claim. They are not just pushing payments out the door. They will flag claims for BAC Nurse review if diagnosis codes or costs look out of line. We also set flags for specific members, codes, benefits, or a certain provider, where we feel any claim matching the parameters should be pended for clinical review.