WHAT SETS US APART

TOTAL CLAIMS REVIEW AND MANAGEMENT, INC. has developed a balanced approach to Utilization Management through an integrated and customized package of cost-containment services based on our years of experience in focusing our interests and efforts to address the health care needs and administrative considerations of health benefit plans.

The successful working relationship that we have developed and enjoyed with our clients has enabled us to gain an appreciation of not only the health care needs, utilization patterns, and demographic considerations of the participants, but also of the philosophy and approach regarding Plan administration priorities.

Through our years of experience in developing this balanced approach, we have developed an understanding and ability which enables us to effectively address and respond to the unique perspectives, procedural preferences and requirements of our clients. In our crusade to effectively lower health care costs by implementing effective Utilization Management procedures, we are able to deliver an unfragmented program.

It is our goal to incorporate all of these considerations into this product. We can do this by partnering with you in your efforts to achieve optimal outcomes with respect to both the delivery of quality, accountable, and medically necessary care to your participants by their chosen providers while promoting a strong advocacy and support system for the participants, as well as cost-containment for the Plan. Moreover, our intervention by our team of experienced Certified Case Management Nurses and Physician Advisors provides a strong support system, resource and advocacy source for the participants in potentially stressful and complicated times.

Certainly, our experience validates our conviction that unnecessary, inadequately coordinated and loosely thought-out care, translates into very costly, wasteful, and poor quality care.

OUR MISSION

• To generate a positive impact on cost-containment and the provision of high quality care to the participants with the best interest of both the patient and the payor in mind.

• To implement a flexible, balanced and comprehensive approach to solving the Plan's dilemma of reducing unnecessary hospital days and procedures, and inappropriate and/or inefficient care choices while promoting and maintaining quality care.

• To proactively ensure that the participant receives appropriate care in the appropriate setting with positive outcomes and with a thoughtful approach to cost and Plan eligibility.

OUR GOALS

• To implement a care notification or certification system that will enable proposed care to be identified before it occurs or as early as possible.

• To foster collaboration and cooperation between the patient, the provider, and the payor, and promote increased overall satisfaction and confidence in the administration by the membership by demonstrating a strong commitment to the welfare of the members and their families.

• To significantly reduce health care costs by having the opportunity to collaborate with providers and members proactively and concurrently so that factors such as cost, availability of preferred providers, and Plan eligibility can be examined in advance.

• To utilize the program as a useful tool for identifying high risk/cost utilization trends, and to evaluate the effectiveness of the covered benefits and the language of the Plan document in responding to those trends as well as the ability to authorize and provide flexible cost-effective coverage alternatives.