Evidence-Based Medical Case Management & Utilization Review

GMMI’s Medical Case Management Program uses Best Practices when performing Utilization Review and Case Management.

We utilize the industry’s most reputable published criteria and their medical guidelines on all of our in-patient and surgical cases. Using vetted clinical evidence based on the latest published research can help us determine proper levels of care. The concept behind Evidence Based Medicine is to make sure that decisions made in relation to health care are based on the most up-to-date, solid, reliable and scientific evidence.

Having a solid Case Management Program affords our case managers the tools to provide guidance and oversight to ensure the safest and most effective care to their patients. Our Case Managers' work influence care in ways such as transitioning care to other institutions or to the patient's home, management of the patient in the community, prevention of recidivism or unplanned return to an acute care setting, and anticipation of and planning for repatriation to home country.

• Directing patients to most appropriate and cost-effective facilities
• Coordination of Referrals
• Coordination of hospital admission and medical appointments
• Pre-Authorizations/Pre-Certifications
• On-going monitoring of patients' treatment plans
• Focus on discharge planning starting upon patient admission
• Coordination of follow-up appointments
• Coordination of repatriation/evacuation back to home country

How does our Evidence-Based Case Management tie into our medical claims administration and ultimately benefit our clients?

• The systematic use of published medical criteria supports GMMI’s medical team with clinical indications for admissions and/or procedures. This secures that the entire medical is using the same criteria to give consistent approvals (approvals made based on client specific policy guidelines & coverage restrictions).
• Goal Length of Stay is outlined in the criteria which are crucial for decision-making support in determining a reasonable length of stay for in-patient procedures and medical conditions.
• Benchmarks and Data Management tools are outlined and it provides GMMI with statistical bench marking to help measure and track variations in length of stay and readmission rates.
• Effective use of the Case Management criteria strengthens the claims adjudication process. Approved Length of Stay and approved procedures are tied back to the claims adjudication process. Services billed in excess of the approvals are reviewed and challenged.

By adhering to the medical criteria, GMMI delivers on the promise to clients of providing complete cost containment solutions. EBCM is a valuable tool that supports our mission to carry patients from sickness to health, distress to relief - anytime, anywhere.