Additional Services

Surgery Decision Support: Predictive Outreach

ConsumerMedical offers a Surgery Decision Support (SDS) program that focuses on addressing five common elective surgical procedures where two or more medically acceptable options may exist and where patients have choices among treatment options:

Lower back surgery
Hip replacement
Knee replacement
Hysterectomy
Weight loss surgery

To drive additional engagement in these surgeries, ConsumerMedical offers Predictive Outreach.

Predictive modeling is an important tool that ConsumerMedical has been using for nearly a decade to help drive successful targeted outreach. It answers two primary questions:

    1. Who is at risk? And…
    2. Who possesses the greatest impact opportunity?

By leveraging our proprietary models, third-party data warehousing and analytics capabilities, we identify high-value members for outreach and engagement.

Predictive Outreach Benefits / Results

Predict future costs and engage high risk patients
Your claims data with our analytics and outreach drive 33% better engagement into our Surgery Decision Support Program
Engage 50% of likely candidates before surgery occurs

Employers can expect that 2.58% of their
population will have one of these surgeries each year.

With Predictive Outreach, we can reach
about 50% before surgery occurs.

Surgery Decision Support: Requirement/Penalty Model

For customers using our Surgery Decision Support (SDS) program (described above), ConsumerMedical integrates, funds and administers a $400 incentive (included in PEPM fees), leading to better health outcomes for members and direct cost savings for employers.

For maximum engagement potential, ConsumerMedical offers the Surgery Decision Support Requirement (penalty model) that helps induce participants to proactively select high-value care (i.e., those treatments and procedures backed by strong evidence of efficacy) by requiring that they complete the SDS program or face a penalty. (Note: When the requirement is introduced, the incentive is no longer funded.)

To implement the SDS penalty model, ConsumerMedical partners with the customer’s health plan to integrate a requirement for participants to engage in the SDS program prior to having one of the designated surgical procedures. Importantly, after completing program requirements, participants are free to make any decision they want on treatment. If program requirements are not met, however, participants will pay a defined penalty of $500 – $1,500 (dollar amount determined by the company). For this requirement to be successful, it is important that an integrated communication strategy begin 4-6 months prior to the launch date and that a customer’s health plan can administer specific components of the penalty for the program.

SDS Benefits / Results

Up to 43% avoid unnecessary surgeries (knee replacement, lower back, weight loss, hip replacement, hysterectomy)
$26,125 per-case savings from avoided surgery
Influence treatment path of the most avoidable surgeries with incentive/penalty
Unlocks 100% Fees at Risk option.

ConsumerMedical works with leading data
analytics partners and tools to develop and refine
the most accurate model for evaluating
Surgery Decision Support ROI.

Integrated Claims Advocacy

Support for the Entire Healthcare Journey
Claims Advocacy saves you time and offers peace of mind knowing your employees are getting the help they need with billing concerns—and learning valuable healthcare consumerism skills in the process. The entire ConsumerMedical Ally Team works together to make sure employees receive the right support at the right time.

You and Your Employees Have an Ally to Help with Billing Errors and Concerns

Confidential, independent support and peace of mind
Simple clarification of coverage and benefits, EOBs and medical bills
Potential cost savings due to increased accuracy of coverage and billing

The Claims Advocacy Experience

We save employees valuable time and reduce stress, allowing them to focus on their jobs, families and health/recovery. The service is structured, yet simple and includes:
Consent to share PHI
Collection and review of bills and statements
Research and calls to health plans and providers
Assistance understanding the appeals process
Regular status updates for the employee
Documentation of case details and decisions

High Cost Conditions – Cancer Quality Program

Support Employees Who Need It Most
ConsumerMedical’s Cancer Quality Program specifically targets individuals who have been diagnosed with cancer or are potentially on the path to a cancer diagnosis. Our sophisticated algorithm—developed with a leading actuarial partner and our clinical experts—allows us to identify and reach the right people at the right time, when initial treatment decisions are being made.

Proactive, multi-channel outreach to identified individuals on a monthly basis
Monetary incentive administered and funded by ConsumerMedical
Specialized oncology decision support built on the 5 Drivers of QUALITY CARE
Delivered by a Medical Ally team that includes an oncologist and oncology nurse

Program Requirements

Ally TotalSupport or Ally ExpertOpinion & Surgery Elect
Surgical Decision Support Predictive Outreach
Monthly medical and pharmacy claims data
Use of ConsumerMedical’s data warehouse or remote access to employer data warehouse