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KEPRO Utilization Management is the first line of defense to manage healthcare costs, while ensuring your members receive the right care, at the right time, in the right setting.
Healthcare Costs are Rising Rapidly.
How does this impact you and your members?
- Total health expenditures reached $2.6 trillion in 2010, ($8,402 per person) and 17.9% of US Gross Domestic Product (GDP)
- Projections show that US health expenditures will account for 19.6% of US GDP by 2019
- Hospital expenditures grew 4.9% in 2010, totaling $814 billion
To counter this trend, you need powerful solutions that serve your members and your ROI.
Your Members Get the Right Care, at the Right Time, in the Right Setting.
KEPRO has 8 staff medical directors and a panel of more than 3,200 experienced peer reviewers available for review and consultation. Our expert clinicians apply nationally recognized guidelines and criteria to validate the medical necessity and level of care for services across the continuum.
Our URAC accredited health utilization management program includes:
- Prior authorization of inpatient and outpatient services
- Surgical procedures and transplants
- Behavioral health services
- Extended outpatient therapies
- Radiology services
- Durable medical equipment
- Retrospective review
- Prior authorization for organ/ tissue transplants and nursing services
- Concurrent review
- Discharge planning and care management program referral
- Appeals (first and second level)
KEPRO Thoroughly Assesses Necessity and Care Levels.
We use recognized clinical criteria, plus eligibility and benefit plan design, to assess medical necessity and level of care. Our nurses channel members to network providers or negotiate out-of-network fees to secure the highest quality, most cost-effective services. We conduct concurrent reviews to determine if continued inpatient days or outpatient services are necessary.
We Take a 360° Approach to Discharge Planning and Follow Up.
Assessment for discharge planning, care coordination, and case management intervention is a standard part of our process and begins at the time we receive a prior authorization request. We coordinate with the facility discharge planning staff, the patient, and physicians throughout the hospitalization to ensure a timely discharge when the patient’s condition warrants it. If post discharge follow up is required, we refer the patient to our Case Management program for a seamless transfer of care coordination services.
Proprietary Early Identification Helps Cut Costs.
The most critical component of our program allows us to identify members who would benefit from more intensive care management services. Our process is driven by a set of proprietary analytic tools and statistical algorithms designed to identify the risk burden of your population. Using established triggers, we identify high cost and high risk members with multiple, complex co-morbidities. Then, we refer them to our (or another vendor’s) Case Management, Chronic Care Management, Specialty Case Management (oncology), or Maternity Management programs.
KEPRO Provides Proven Results for Your Members and Your ROI.
We measure program success based on financial and clinical outcomes.
Our standard measurements include:
- Average length of stay
- Bed days per 1,000 covered lives
- Admissions per 1,000 covered lives
- Savings and ROI
Our clinical reports also show your top 25 diagnoses for acute and outpatient costs associated with these services, as well as denial and appeal volumes. We provide trends over time, which can help you design a more effective benefits plan and have more satisfied participants.