Find an Answer

FAQ Public And Commercial

Back

What is the value of integrating your medical management programs?

An integrated approach of utilization, case, chronic care, and specialty case management programs, such as oncology and maternity management, is the most cost effective way to manage the health of your total population. Specifically, an integrated approach eliminates barriers by addressing all of the physical and behavioral healthcare needs of each participant rather than treating one issue or condition at a time, ignoring the total health and treatment needs of each participant.

Early Identification and Referral

An integrated approach allows KePRO to perform a single source claims analysis so that we can identify the appropriate program and interventions based on the member's overall healthcare needs. Each member works with one case manager to address all care needs, without the duplication of efforts and confusion arising from multiple calls to different programs.

Predictive Modeling

To ensure that care management programs have the most impact, you must first understand the current and future risks of your individual population. KEPRO performs predictive modeling using claims data to identify potential participants with utilization patterns and conditions that may benefit from care management interventions, including participants with multiple providers, poly-pharmacy, or gaps in care.

KEPRO's predictive modeling can improve the targeting of care management programs by:

  • Predicting the recipients most likely to incur high costs
  • Determining recipients in this high cost group who have avoidable costs
  • Identifying specific gaps in care that, with appropriate intervention, will reduce disease progression and exacerbations and reduce care costs.
  • Identifying specific cost drivers that will benefit from focused programs, such as oncology, heart failure, or advanced illness.

KEPRO also uses our utilization management program to identify and refer candidates who would benefit from other care management programs. Using triggers embedded into our proprietary medical management system, we can identify these participants early, often when they are still in the hospital, and engage them in our more intensive programs. Being able to engage participants early and often while they are still hospitalized increases participation rates and further demonstrates the benefits of KEPRO's integrated care management approach.

We also use biometric data captured in our wellness program to identify and engage candidates for more intensive intervention, including those who are at increased risks for chronic and other conditions. And with our proprietary, integrated medical management platform, we seamless move members to appropriate programs as their care needs change.

If you use a separate vendor for utilization, care management and wellness, the lack of communication among vendors or delay in the identification process costs you money. More than 20 percent of persons discharged from the hospital are readmitted within 30 days of discharge (Centers for Medicare & Medicaid). And an April 2013 study published in The Annals of Emergency Medicine found that a quarter of the patients discharged from Boston Medical Center during the first half of 2010 resulted in at least one emergency department visit within a month after the patients left the hospital. And 54 percent of those visits to the emergency department did not lead to a readmission, but increase health care costs.

Addressing Total Health Care Needs

KePRO’s integrated approach to care management improves total health and well-being by addressing each participant's comprehensive health needs. We are successful because we employ a primary case manager model and conduct thorough assessments based on participant needs.

Primary case manager (PCM) model

Studies demonstrate that patients who identify with one person (such as a personal physician, or case manager) have significantly better health outcomes than those who see multiple providers for their healthcare (De Maeseneer JM, De Prins L, Gosset C, et al. Provider continuity in family medicine: Does it make a difference for total healthcare costs? Ann Fam Med. 2003; 1:144-8.). Assigning a registered nurse to serve as each participant’s PCM enables us to provide better care coordination, increases our ability to address all conditions and co-morbidities, and facilitates strong relationship-building with both participants and their providers.

We assign a PCM to further assess each participant’s health and enroll the individual in the appropriate care management program. We assess general quality of life and physical and behavioral health and all co-morbidities (including mental health), to identify barriers to compliance, health literacy related to condition and prognosis, and readiness to change. For hospitalized participants, we identify barriers that prevent the participant from complying with the discharge to home and/or medical treatment plan as prescribed by the provider, including medication adherence, follow-up office visits, etc. And for those identified as candidates for our chronic care management program, we conduct condition-specific assessment as warranted.

We reassess participants at varying intervals, and move them seamlessly (using our proprietary medical management system) to other programs as their care needs change. The PCM retains primary responsibility for coordinating all interventions in the participant’s case, and works closely with other healthcare team members, such as a maternity case manager, to support the participant’s short and long term needs.

Find an Answer

Please describe KEPRO data security that ensures member information is protected.

As an organization that is charged with storing and transferring Protected Health Information (PHI), KEPRO is bound by HIPAA regulations, and is accustomed to managing the security and privacy of PHI. KEPRO currently exchanges data successfully and confidentially via secure encrypted means in support of all of our federal, state, and local government programs, and with commercial clients.

KEPRO has been implementing and supporting systems that require medical record, data security, and transmission for more than a quarter of a century, and has always placed primary importance on using systems that allow for fast and efficient connectivity, while still providing the highest level of data and system security. Our proven internal and external policies and protocols ensure compliance with state and federal laws and regulations, as well as any additional security measures you may require.

We have a stringent KEPRO Comprehensive Confidentiality Plan that governs our processes. KEPRO’s Privacy Officer, Security Officer, and the Compliance Officer have ultimate responsibility for oversight of the processes and procedures contained in the KEPRO Comprehensive Confidentiality Plan.

KEPRO's system is secure. Our information systems are secured by an in-depth strategy that utilizes multiple layers of operational, management, and technical controls to protect KEPRO assets. We also employ software programs designed to prevent unauthorized use by staff or outside entities.

All KEPRO information systems employ common security controls such as Firewalls, Anti-virus, Role Based Access, FIPS 140-2 Encryption for mobile devices, and the requirement of strong passwords. Information system users are assigned a security role based upon access requirements relevant to their positions and information/program privileges.

The HIPAA Security Rule requires entities to implement information systems that control access to healthcare and related systems. KEPRO adopts a subset of NIST 800-53 Rev 3 Security controls to maintain compliance with HIPAA. Based on these security standards, KEPRO mitigates risk to its Information system by focusing on such controls as:

  • Log-In Security. HIPAA security requires the use of secure User IDs and the use of passwords. KEPRO requires multiple account authentication processes within its information systems to verify the identities of our end-users. KEPRO's policy requires strong passwords that are changed frequently.
  • Access Control. HIPAA requires one of the following: Context Based Access, Role Based Access, or User Based Access. User Based Access is part of the Log-In Security component. KEPRO's Role Based Access gives individual users access relevant to their function in the organization.
  • Audit Trail. HIPAA requires the use of an audit trail to identify who accesses PHI. KEPRO systems track those who change the patient record, the date and time the record was modified, and the specific information changed. The system includes a read only audit trail that captures each time a system user views a case.
  • Session Time-out. KEPRO information systems account for session inactivity by locking screens after 10 minutes of inactivity.
  • KEPRO's physical space is secure. KEPRO’s computer, telephone, and hardware systems are located in climate controlled rooms with fire-suppression and electronic locking system. We allow only authorized access to the room.
  • KEPRO focuses training on confidentiality and security issues. All KEPRO employees undergo rigorous training on security and confidentiality of PHI. We have successfully provided this training to all staff regardless of their respective roles/duties.

KEPRO Headquarters

See all locations

777 East Park Drive, Harrisburg, PA 17111
Toll-free: 800.222.0771
Phone: 717.564.8288
Fax: 717.564.3862