The NAMM Health Services Department is committed to the delivery of health care services which demonstrate effective outcomes to optimize your clinical and financial performance. This is accomplished through patient-centered delivery of care which is administered in an equitable and efficient manner.

We focus on improving quality of care for your members through proven programs that balance utilization, maximize operational efficiencies, and contain cost. Our multi-disciplinary approach works with your physicians and clinicians, tailoring to the needs of your medical group through:
  • Adopting nationally recognized evidence-based guidelines
  • Developing policies and procedures to achieve organizational goals
  • Evaluating and analyzing outcomes against national and local benchmarks
  • Proactive, comprehensive reporting of utilization and cost statistics
  • Communicating results and developing action plans to further enhance programs and outcomes
Utilization Management:

Ambulatory: NAMM’s goal is to effectively coordinate provider care requests in a timely and efficient manner, determining and communicating the most appropriate utilization of services for our members. This is accomplished through:
  • Local call center
  • Use of national, evidence-based and medical-group-specific guidelines
  • Medical Director medical necessity denial process
  • Denial and appeal process that is compliant with NCQA guidelines and all state and federal regulations
  • Leverage electronic referrals whenever possible
Inpatient: NAMM’s Utilization Management Nurse facilitates inpatient utilization by working collaboratively with the member’s primary care physician, the specialty care physician, medical director, hospital ancillary staff, and discharge planners to coordinate member medically appropriate services in the most optimal manner.

The NAMM Utilization Management Nurse is also responsible for assisting and facilitating the coordination of hospital transfers and identifying all available care options to maximize the most appropriate and efficient levels of care needed. NAMM provides proven, effective case management that follows your members from initial admission through discharge and home care needs, including:
  • Daily prospective, concurrent, and retrospective review of all inpatient cases including behavioral health
  • On-site and remote utilization review capabilities
  • Group and provider level inpatient analysis, tracking and trending that complies with state and federal regulations
  • Identification of care alternatives to maximize patient benefits, outcomes, and cost
  • Coordination with health plan staff
  • Expertise with UM and peer review committee operations
  • Utilization statistics that meet and exceed the goals of well-managed nationally recognized guidelines
  • Managing transfers of out-of-network cases in network
Case Management:

The NAMM Case Manager identifies members with multiple or complex conditions, partners with primary care physicians, and assists with the coordination of care for that member. Care coordination includes assessment, planning, implementation, coordination, monitoring, and evaluation of the member’s needs. Our team adheres to preventative care guidelines as defined by HEDIS, NCQA, and other local and national protocols to promote compliance and reduce unfavorable events (e.g., re-admission, emergency room visits, etc.). The goal is to help our members regain optimum health or improved functional capability and an improved quality of life.

The Case Manager utilizes available resources to promote quality cost-effective outcomes while ensuring that care is provided in the most appropriate setting at the most appropriate time, all while maximizing the member’s health plan benefits.

These objectives are accomplished by working closely with the member, the member’s physician, ancillary service providers, and the member’s health plan. Our Case Managers utilize cutting-edge software systems, nationally recognized evidence-based care guidelines, and follow NCQA requirements so that you can be assured that your member is receiving the best coordination of services possible.

Quality Management:

The NAMM Quality Manager coordinates health plan projects and HEDIS requirements through educating the physicians and staff regarding project specifics and coordination of data collection activities. Project analysis is provided to each individual provider, with group trends reported at monthly meetings.

Services include:
  • HEDIS and quality projects as directed by the health plans
  • Perform advanced and sophisticated outreach: physician and member programs
  • Annual education seminars
  • Assists Physicians in preparation for Health Plan site visits and audits
Compliance:

Compliance with health plan and governmental regulations is delivered by NAMM’s experienced and focused staff that ensures the timely and accurate submission of health plan, Medicare- and Medicaid-required reports which may include:
  • Complaints
  • Denial and appeal logs
  • Encounter data (FFS and capitated services)
  • CMF oversight reports
  • Utilization statistics, benchmarking against national criteria
Our dedicated compliance staff assists with health plan audits, UM planning, and program preparation. NAMM has recently been chosen by Blue Cross Blue Shield of Illinois (BCBS) to serve as a beta testing site for the BCBS MXO application program. This project illustrates our ability to effectively gather and process quality data for direct electronic submission to the HMOs.

Integration with other NAMM departments:

NAMM Health Services Department interfaces with all other departments within NAMM to bring the client a fully rounded approach to managing their needs. For example, interaction with the Analytics and Finance Departments through our Health Care Cost meetings lead to a multi- disciplinary approach to identifying opportunities to lower costs while maintaining high quality of care. Health Services interacts with the Provider Relations Department when it identifies issues related to opportunities to lower costs related to contracting or other health delivery system issues. Analysis of claims data allows monitoring ongoing trends to identify problem areas that need attention and the impact of strategies implemented to reduce costs. Health Services’ expertise in health service delivery, cost of care, and knowledge of industry standards can allow you to move your delivery of services to higher profitability.