Medical management

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Milliman's UK healthcare consultants offer detailed knowledge of the critical success factors needed to create a world-class medical management programme. We assist clients with identifying the most cost-effective programmes and offering the best financial and quality outcomes for a client's specific operating environment.

Our extensive expertise extends to all types of medical management functions, including inpatient concurrent reviews, post-discharge reviews, ambulatory case management reviews, disease management, and claims and underwriting management. Our team excels in benchmarking the efficiency of medical management departments against local and global best practices.

Operational reviews pinpoint problem areas

Our consultants conduct extensive on-site operational reviews utilising our proprietary global industry benchmarks. We examine the culture, procedures, and staffing skill mix of an organisation, then analyse the client's data within that context. Our team then offers specific recommendations for improving medical management efficiency.

Milliman's analysis extends beyond medical management to examine the interactions between the medical management department and other departments, such as underwriting, finance, and management reporting. This approach ensures that improvements proposed in medical management are linked with the goals of other departments, avoiding the issues arising from competing priorities and misaligned incentives within an organisation.

We assemble multinational, multidisciplinary teams to conduct operational reviews. Our consultants include actuaries, physicians, and other clinical staff, bringing an unusual breadth of healthcare knowledge to this task.

Case study: Reorganised for better ROI

Milliman was asked to investigate the medical management and claims control functions at a large UK insurer. We conducted a four-day on-site consultation to review claims processes, underwriting, and medical management functions, including the pre-authorisation procedures.

We also reviewed the efficiency and decision-making processes used by the specialist medical teams that determine the suitability of large and complex claims. In addition, we examined the case management function for specific types of high-cost claims, including chemotherapy and orthopaedic procedures.

We identified several areas where the skill mix among case managers performing these functions was sub-optimal and the insurer was not maximizing its potential return on investment (ROI) As a result, the insurer reorganised its entire medical management function, introducing evidence-based guidelines to promote consistent decision-making and redeploying some clinical staff to areas with better ROI.