High Risk Claims (2)

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High-Risk Claims

Table of Contents



High-Risk Pregnancy


Gene and Cell Therapy Program


Oncology Management


Specialty Pharmacy


AultCare’s Medical Directors


Contact Us



Introduction As a provider-sponsored healthcare plan, AultCare’s close relationships with network providers encompass several advantages for its members. A member’s care is streamlined and coordinated between the health plan and provider, and ultimately helps control healthcare expenses.


High-Risk Pregnancy To promote the health of women with a high-risk pregnancy, AultCare offers a successful High-Risk Pregnancy program. The program promotes a robust identification practice, a concentrated engagement process, and measurable outcomes. Process and Intervention AultCare’s High-Risk Pregnancy Program consists of four components: early identification, member assessment, risk stratification through the removal of barriers and identification of intended outcomes, and high-risk maternity solutions. Identification AultCare’s objective is to identify high-risk pregnancies as early as possible. One way to achieve this is by reviewing claims data. Other factors contributing to this identification process include:  Individual predictive modeling  Increased communication with Obstetrics and Gynecology (OB-GYN) practices  Implementation of an assessment for those high-risk pregnancies Member Assessment The AultCare Case Management and Disease Management teams work alongside the member to complete an assessment of the mother’s current health and needs, and the future needs of the baby.  Age  Medical risk  Mental health  Substance abuse  Past birth history  History of Spontaneous Abortion (SAB)/Therapeutic Abortion (TAB)


High-Risk Pregnancy Removal of Barriers and Identify Intended Outcomes Members are placed in a specific risk stratification class based on their level of risk and specific healthcare professional needs. 1) Low Risk a. Members are advised to complete routine prenatal care. 2) Mild Risk a. A chronic disease state has been identified (i.e., high blood pressure, high blood sugar). b. Members will require more hands-on care and follow-up from AultCare’s clinical team. 3) High Risk a. AultCare’s clinical team coordinates appointments to pediatric specialists and specific testing. b. Care coordination encompasses Durable Medical Equipment (DME), medications, testing, usage of network providers, and benefit utilization. c. Referral management for cost effective usage of resources. d. Self-management education, risk factors, diet, signs of preterm labor and other complications, maternal health during and after pregnancy, as well as childcare. Engagement Incentive To encourage impacted members to participate, AultCare offers an incentive upon successful completion of specific levels of care based on their individual needs.  Completion of prenatal care.  Participation in appropriate identified risk level interventions.  Completion of postpartum care. Outcomes Through the course of this program, AultCare focuses on these goals.  The successful delivery of a healthy newborn and the health of the mother.  Help lower PMPM costs.


Gene and Cell Therapy Program AultCare offers an industry-leading solution, in its collaboration with Emerging Therapy Solutions (ETS), for managing the risk associated with the emergence and rapidly evolving space of gene and cell therapies. This service includes a defined Centers of Excellence network that focuses on specific therapies, plan document wording, and benefit design that drives the best outcomes and cost. AultCare collaborates with leading health systems with a history of participating in clinical trials to allow for an additional avenue for sourcing new and complex gene and cell therapies. This program supports to monitor thousands of clinical trials to determine what therapies will be coming to market and forecast exposures. The program also mitigates risk through access to expert panels of physicians and clinical guidelines that ensure members receive the appropriate treatments based on their sound criteria. Identification Process  Prior Authorizations.  Data mining from claims data.  Predictive modeling of patient populations.


Gene and Cell Therapy Program Risk Management Process The AultCare Gene and Cell Therapy program includes:  Ongoing monitoring of clinical trials and specialty drug pipeline by ETS.  Access to specialized expert physician panels and clinical guidelines.  Facilitates to control costs and promote quality by: o Establishing a Centers of Excellence Network. o Leveraging unit costs through direct manufacturer rates. o Establishing quality care standards and coverage criteria. o Providing clear plan language for coverage of drugs. o Helping to control Stop Loss expense through improved identification and evaluation of patients. Outcomes This program monitors the following indicators and compares them against national standards.  Treatment incidence and prevalence by therapy.  Total plan gene and cell therapy costs.  Therapy costs per treatment.  The number of available therapies and related qualified patients.


Oncology Management AultCare’s Oncology Management Program includes a comprehensive, integrated approach to managing cancer conditions. With early detection of care coordination opportunities, evidence-based treatment plans, and our partnership with eviCore, AultCare provides quality and safety processes along with controlled costs and measurable outcomes. eviCore empowers the improvement of care by connecting patients, providers, and health plans with intelligent, evidenced-based solutions to enable better outcomes. eviCore promotes transparent, shared decision making and ongoing education for new products and standards in the marketplace. Identification 1. Utilizing the Prior Authorization process (Medical and/or Pharmacy). 2. Data mining from AultCare’s claims data. 3. Referrals to the AultCare Case Management team from the Primary Care Physician (PCP) or Oncologist.


Oncology Management Process AultCare’s Care Coordination teams reach out to members once a diagnosis is received. Utilizing evidenced-based criteria, AultCare’s clinical teams facilitate to:  Administer educational support and resources.  Reduce Emergency Department utilization.  Reduce hospital admissions.  Provide patient navigation through the complex system. Early   

detection and notification promote to support: Appropriate network adherence. Cost control. High-quality outcomes.

Once identified, each patient is followed on an ongoing basis through the entirety of care to ensure access to appropriate providers and treatment, as well as cost and utilization control. Outcomes Various metrics are reviewed as an indicator of high-quality care and cost control. Some of these metrics are: 1. Emergency Department utilization. 2. Referral destination and site-of-care. 3. Patient navigation. 4. PMPM costs.

AultCare’s Utilization Management Team


Specialty Pharmacy AultCare uniquely integrates local, expert pharmacy management with the external national strength of OptumRx Pharmacy Benefits Manager and two exclusive specialty pharmacies: OptumRx Specialty Pharmacy and Gentry Specialty Pharmacy. This integrated approach helps ensure members receive high-quality and optimal care while controlling costs when utilizing high-cost specialty drugs. Identification  Prior Authorizations identify potential high-risk claimants, promotes high-quality, appropriate treatments, and supports cost control.  Data mining from claims data.  Referrals throughout AultCare’s Care Coordination team.  Collaboration with specialty pharmacies.


Specialty Pharmacy Process  With the use of highly effective editing systems in place, high-cost specialty drugs require Prior Authorization or pertinent utilization management tools utilizing evidenced-based criteria. o Prior Authorizations are developed for immediate impact, but also to consider possible future impacts on medical costs.  AultCare’s Pharmacy and Therapeutics Committee reviews and approves Prior Authorization requests to ensure the proper drug and dosage are being utilized, and the appropriate site-of-care. o If approved, each case is re-evaluated at an appropriate frequency to ensure the efficacy of the treatment program.  While not only based on cost savings, the selection of a Specialty network helps provide clinical services, including member education, medication adherence, ability to recognize potential stockpiling preventing unnecessary dispensing, proper storage, and safe use.  AultCare educates members and providers on the potential cost savings for Generic Specialty Savings (GPS) by directing members to less costly pharmacies through the Prior Authorization process, if applicable. Outcomes The integrated AultCare program for high-cost specialty drugs monitors the following on an ongoing basis:  Quality o Adherence and overall effectiveness.  Safety o Monitored by a combination of the Prior Authorization process, system controls, and AultCare’s, in partnership with Optum’s Fraud, Waste and Abuse program.  Cost Control o Monitored through the Prior Authorization process aided by rebate optimization, and the contracting and network of administration for medications. AultCare’s Commercial and Part D Pharmacy Team


AultCare Medical Directors AultCare’s physician leadership team guides, oversees, and directs our Care Coordination and High-Risk Claims program.

Dr. Haban AultCare Chief Medical Director

Dr. Rich AultCare Medical Director Behavioral Health Dr. Haban AultCare Chief Medical Director

Dr. Wymyslo AultCare Medical Director Quality & Pop. Health Management

Dr. Samaan AultCare Medical Director Utilization Management Dr. Rich AultCare Medical Director Behavioral Health

Dr. Boutros AultCare Medical Director Strategy Dr. Rich AultCare Medical Director Behavioral Health Dr. Haban AultCare Medical Director Dr.Chief Marvin

Dr. Haban AultCare Dr. Westerbeck Chief Medical Director

AultCare Medical Director Post-Acute Dr. Rich AultCare Medical Director Behavioral Health Dr. Haban AultCare Chief Medical Director

AultCare Medical Director Workers’ Compensation Dr. Haban AultCare Chief Medical Director 11

Contact Us

2600 Sixth Street SW Canton, OH 44710 330-363-6360 | 1-800-344-8858 www.aultcare.com Please contact your Account Representative to discuss in further detail.


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