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NGS CoreSource Services
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Managed Care Programs
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NGS offers health care management programs across the entire continuum of care from Health Risk Appraisals and wellness programs to case and disease management.
Provider Relations/Network Management
NGS CoreSource is in the unique position of being able to bring our plan sponsor-clients optimal network solutions in every area of the country. We have established working relationships with numerous PPOs throughout the country including regional, national, and carrier-based networks.
NGS has also developed and interfaced with direct contracted employer/provider arrangements in areas where networks were not available. NGS' provider relations staff can assist the client with network reviews at any time, including access studies, disruptions, full repricing and quality comparisons.
Utilization Review
Utilization review is performed on site at NGS through a URAC accredited program field. A unique capability of our UR process is that the review is not limited to clinical review of the proposed treatment - rather both eligibility and benefits are reviewed with each call. This integrated approach minimizes confusion for plan participants and providers who are not required to make a second call to confirm eligibility and benefits, and are not surprised by a denial under plan provisions after approval under medical criteria.
The review staff is composed of Intake Coordinators and Registered Nurses. The patient or patient representative, including authorized family members, physician, or facility/provider rendering service can initiate phone contact to our UR Department. Comprehensive edits automatically trigger cases for case management review. Additionally, the UR Nurse assesses information about the patient's discharge planning needs to assist with finding network providers and/or determine appropriateness for case management negotiations.
Case Management
Registered Nurses function as advocates, negotiators and educators to help patients transition from inpatient care to step down care or home and assisting patients with education and resources during a time of serious illness. All case management nurses have a minimum of 5 to 8 years clinical expertise and access to a full time medical director as well as panel physicians. Cases are assigned to nurses with appropriate field experience in such specialties as maternity, oncology, cardiac, pediatric, transplantation and psychiatric/substance abuse. The URAC accredited program is fully integrated with NGS' other medical management programs, including UR and disease management and averages more than $5 to $1 return on investment.
Disease Management
The goal of our disease management program is to intervene prior to a catastrophic event by assisting the member with disease and treatment education and self care techniques. Candidates for the disease management program are primarily identified through sophisticated predictive modeling tools which combine medical and pharmacy data to evaluate clinical risk profiles for all members of the group. Disease management referrals may also come from the health risk appraisal, claims referrals, or self referrals. The program uses an intensive care management approach, using nationally recognized treatment protocols and making use of community resources whenever possible. Regular reporting illustrates program goals including enrollment and participation details, cost impact on hospitalizations and ER usage, compliances improvements measured against disease specific protocols, quality of life improvement measured by participant survey and overall return on investment.
Nurse Line
NGS also offers a dedicated 24/7 toll free nurse line to assist callers with confidential health care advice and information. Callers have the option of accessing an extensive health information library or may speak directly to a Registered Nurse for counseling, referral to network providers, or information on community services. Nurses educate callers about treatments, lifestyle choices and self-care strategies so that informed patients can make better and more cost effective health care decisions.
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Medical Claims Administration