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Medical Expense Management

By Sheryl Dobson-Wainwright
Posted: 15th October 2012 09:10
Turn Key Captive and Self-Funded Solutions. Creative, customised solutions to manage health care dollars while ensuring that your members get quality, timely and effective medical services. 
Medical Management in the Self-Funded and Captive Market
Self-insurance has been an effective way for employers to provide healthcare benefits to their employees since the early 1980s.  The benefits include flexibility for the employers, efficiency for the employer and members, and control of the way the healthcare dollars for the company are utilised.  With the advent of healthcare reform, self-funding for employers and captives continues to offer these benefits in an otherwise complex system.
Benefits for Captives in the Self-Insurance Market
There are several benefits for a Group Captive when offering medical benefits to their members through a self-insured plan.  These include:
  • Customised, tailored benefit plan design;
  • The ability to hand-select medical expense Management providers, offering transparency and collaborative support;
  • Hand-picked claims processing providers that are HIPAA compliant, offering transparency with the claims data;
  • Benefits of risk pools for underwriting purposes and stop-loss coverage ;
  • Lower state taxes;
  • Stronger cash flows and higher investment income.
Why a Medical Expense Management Company?
Healthcare reform has removed many strategies a self-funded company used to employ to control their healthcare dollars, including limits on certain benefits.  Medical Expense Management companies provide the necessary services such as Utilisation Management, Case Management, Disease Management, Wellness, claims review, and claims auditing services to help the self-insured captive utilise their healthcare resources in the most cost-effective and appropriate way.  In addition, the role of the health care professionals performing these services includes assisting the insured member to access appropriate services in a timely manner, and with maximal Utilisation of appropriate benefits under their Plan.  At Premier Managed Care Solutions, LLC, we also assist members to access community and other resources, as available, when their health plan does not cover a necessary service. 
Utilisation Management
Unfortunately, there is often a misconception about Utilisation Management and Case Management programs.  Premier Managed Care Solutions, LLC, (PMCS), ensures that all decisions are made according to nationally approved criteria and plan benefits, to ensure the member has the appropriate care and services in a timely manner.  All denials for medical necessity are completed by physician reviewers Our Utilisation Management and Case Management staff do not receive any financial or non-financial incentives to deny services.  Utilisation Management services include:
  • Prospective Review;
  • Prior Authorisation;
  • Concurrent Review and Discharge Planning;
  • Retro-authorisation (if approved by the Plan);
  • Attempts to transition to panel providers; and
  • Rate Negotiations with non-panel providers.
Case Management
All Case Management services are provided by Certified Case Managers with more than five years experience.  Our Case Management staff work with clients who have suffered severe illnesses or injuries to help them access the appropriate providers in their area, and to ensure they are aware of their benefits and alternative resources that may be available to them.  Our Case Management programs combine best practices and standard of care services used by leading medical providers in the appropriate specialty, according to state, with the expertise of our certified Case Management personnel.  Our nurse Case managers work closely with the treating providers, members and family to promote optimal care and outcomes for the injured or ill member.  When appropriate, our nurse Case managers attend physician appointments and make home and worksite visits.  Our Case managers develop a customised program for each member to ensure they get the support and education they need to manage their condition, and become active participants in their own care. 
Case Management is the backbone of Managed Care.  The Case Manager coordinates care across service lines and between multiple providers and facilities to promote optimal, timely, and effective care of the member.   The goal is to improve and quality of care, thereby improving the health of the member.  This, in turn, results in decrease healthcare expenses. 
Disease Management
Disease Management programs are specifically designed to assist members with chronic illnesses to become expert managers of their own healthcare needs, and meet their individual goals for medical, personal, and psychosocial health and well-being.  .  As the member becomes more involved in the management of their condition, their quality of life improves and they become active participants in maintaining their health.  The Disease Management personnel work closely with the member and their treating providers to formulate an effective and appropriate plan to promote the member’s successful transition to self-care. 
High-Risk Pregnancy and Health Pregnancy Programs
Our High-Risk Pregnancy and Healthy Pregnancy Programs promote optimal health for mother and baby throughout the pregnancy.  Our care coordinators follow expectant mothers through the term of the pregnancy, offering support and education for questions and concerns that arise.  All participants receive an in-depth risk assessment at scheduled times during the pregnancy, and receive educational material and follow-up as warranted by their risk for complications.  This program can be tailored to include a special gift upon delivery. 
Claims Review and Bill Audit
PMCS has trained staff who can audit claims for coding, provider eligibility, medical necessity, and potential billing errors.  PMCS can also provide on-site or off-site hospital bill audits and facility audits and repricing.  PMCS uses nationally accepted, independent usual, reasonable and customary tables to reprice out-of-panel claims.  If your provider panel contract allows auditing of providers on your panel, we are available to audit their claims and compare them to the contracted rates for accuracy and appropriateness of billing. 
Medical Expense Management Companies continue to be vital part of the cost control and patient care improvement strategies of a self-funded captive group.  National Healthcare Reform exigencies have resulted in employers feeling pressured to provide optimal coverage to their members, while maintaining control over the dollars they spend.  Captives provide that ability to control potential escalating healthcare costs.   PMCS has been providing independent, high quality, cost effective medical expense management services to self-funded employers and groups for over 14 years.  We have the benefit of being a small, flexible company that can meet the needs of each of our clients with optimal outcomes and return on investment. 
Core Values and Guiding Principles
Premier Managed Care Solutions, LLC was founded by Sheryl Dobson-Wainwright, RN, BSN, MBA, CCM, LNCC, CLCP to provide high quality, fully customisable services to Self-Funded clients and Captives in 1998.  Our Goal is to provide an unparalleled customer service experience while delivering the results your company deserves. 
Sheryl Dobson-Wainwright completed her nursing degree in 1984 in New Zealand, and went on to complete a Bachelor’s in Nursing in 1995.  Sheryl has subsequently earned a Masters in Business Administration from the University of Utah in 2009, and has completed the Six Sigma Green Belt – Healthcare, Lean Six Sigma, and the Six Sigma Master Black Belt programs through Villanova University.  Sheryl has several healthcare and nursing certifications. 
Sheryl Dobson-Wainwright can be contacted by phone on +1 801-924-0401 or alternatively via email at

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