Source: Centers for Medicare and Medicaid Services, Office of the Actuary.

Integrated Care at Home

Market Challenge

With an aging U.S. population, a greater incidence of chronic conditions and increased health coverage, the need to manage durable medical equipment (DME) and home health services is growing. By managing patients in the home, effective daily treatment costs can be reduced by 89% as compared to a skilled nursing facility and as much as 98.5% as compared to an acute care hospital setting.[1]
  • Demand for DME continues to grow at an annual rate of 4.8% and is estimated to reach $43 billion by 2019[2]
  • DME waste and abuse is growing as well – estimated at $1.5 billion to $5 billion per year causing unnecessary costs and risks to patients[3]
 

What We Do

CareCentrix is fully dedicated to making the home the center of patient care.  By managing the services, therapies, and resources that enable patients to heal and age at home, we’re able to support plans in meeting the Triple Aim of health care: lower costs, improved outcomes, and higher patient satisfaction.
 
This is particularly important as care continues to shift out of inpatient settings, and healthcare strategies migrate from fee-for-service to value-based care.  By 2018, as much as 50% of Medicare benefits will be delivered under value-based payment models,[4] a fact that underscores the importance of patient outcomes, even when not in a hospital or acute-care facility.
 
Our Integrated Care at Home offering combines the critical components for ensuring a well-managed plan that extends beyond the hospital’s four walls.
 
Home Provider Network.  We provide our clients with access to one of the most comprehensive home provider networks in the nation. We have credentialed and contracted with over 8,000 provider locations for:
  • Durable Medical Equipment
  • Home health services (in-home nursing services by registered nurses, physical therapists, occupational therapists, medical social work services)
  • Home infusion services
  • Respiratory therapy services
  • Orthotics, prosthetics, and medical supplies
  • Our comprehensive credentialing process meets or exceeds the standards of nationally recognized accrediting bodies, such as URAC and NCQA
 
Clinical Support.  Our teams of highly trained nurses, all experienced in specific disease areas and in managing care to the home, coordinate care with physicians, case managers and network providers. We are fully accredited by URAC for Health Utilization Management (UM) through November 2018 and conduct prospective and retrospective utilization reviews of requested home care services. We leverage proprietary data and monitor trends to help enhance the UM policies of our customers, enabling them to make more informed decisions on their coverage policies. Because care at home is our focus and area of expertise, we implement best practices to help ensure optimal outcomes in the home.
 
Care Coordination.  We know that one of the most important drivers of satisfaction is that care in the home starts when it should.  We take extraordinary measures to ensure that the start-of-care date from the physician or discharge planner is met; on average, we meet the start-of-care date 99.3% of the time, in many cases coordinating among different home care providers.  To help ensure that providers have been able to fulfill services by the prescribed start-of-care date, CareCentrix performs a service validation program, in which we contact patients 24 hours after the documented start-of-care date to confirm that the service was delivered on time and with adherence to quality standards.
 
Reduced Administrative Burden.  Plans often contract with us for eligibility determinations, claims processing and payment, billing (to both providers and members), member services and engagement, as well as to minimize Fraud, Waste, and Abuse.
 

Benefits

CareCentrix’s Integrated Care at Home program relieves plans of the complexity and burden of administering end-to-end care at home through an efficient and scalable approach. The program facilitates appropriate, cost effective, and patient-centered care without compromising quality that can:
  • Reduce the risks and costs of fraud
  • Coordinate the services and equipment patients need in a timely fashion
  • Reduce unnecessary costs and risks attributed to institutional settings
  • Help patients manage their condition within the comfort, privacy, and health enhancing environment of home
 
[1] http://www.aoa.gov/Aging_Statistics/
[2] http://www.harriswilliams.com/sites/default/files/industry_reports/DME%20Industry%20Update.pdf
[3] http://www.bio-medicine.org/medicine-technology-1/NICB-Report-On-Durable-Medical-Equipment-Fraud-30000-2/
[4] http://www.hhs.gov/about/news/2015/01/26/better-smarter-healthier-in-historic-announcement-hhs-sets-clear-goals-and-timeline-for-shifting-medicare-reimbursements-from-volume-to-value.html