SERVICES
- PPO/TPA Services
- Specialty Services
- Oncology Risk Management
- Solid Organ/Bone Marrow Transplantation
- Pharmacy Benefits
PPO/TPA Services
For the international payer with a need to access health care services throughout the world, the challenges are considerable. We approach each payer as unique, requiring a customized approach and personal attention.
PPO Services
Network Access - QHM PPO networks provide excellent value and access.
Member Services - QHM manages the details of each patient’s care, coordinating with payers, patients, and referring physicians in determining the most appropriate provider options within the QHM network.
Case Management - QHM works with the patient, provider and payer to manage the clinical and cost impact of catastrophic cases.
Air Ambulance - QHM provides pre-negotiated discount air and ground ambulance services around the world.
Claims and Customized Reports - Claims reports are provided weekly document patient activity, billed vs. paid claims and savings documentation.
Additional Features-Web Viewer Client Access, Lab claims management, Dental Networks, Second Opinion Services
Third Party Administration Services Within the text of managing both the health care of the patient and the financial responsibilities of the payer, QHM provides the following TPA services:
- Precertification
- Admission Authorization
- Concurrent Review
- Discharge Planning
- Catastrophic Case Identification
- Claims Review
- Claims Repricing/Adjudications
- Claims Audit
Specialty Services
QHM has identified medical care that requires a specialized approach due to the complexity and cost of that care.
- Oncology Risk Management
- Solid Organ/Bone Marrow Transplantation
- Pharmacy Benefits
Oncology Risk Management
Problem: More than 1.4 million new U.S. cancer cases will emerge this year with an average treatment cost of $80,000. Unfortunately, traditional models of medical cost management often shift costs or deny care while leaving patients, physicians, and payers disconnected.
QHM Solution: QHM has partnered with ITA Partners, the world’s only independent oncology risk management company. ITA Partners implement strategies to that lower claims costs while improving a patient’s experience during the continuum of care. ITA Partners Provides validation, access and transparency in the delivery of cancer care to patients, physicians and payers.
Solid Organ/Bone Marrow Transplantation
Problem: The emerging technologies, new surgical procedures and innovative drug therapies almost guarantee that the science of transplantation will continue to advance for the foreseeable future. Payers must quantify and identify the best transplant centers for patients to access, while achieving cost containment objectives in this high-cost clinical field.
QHM Solution: Cigna LifeSource Transplant Network offers QHM clients access to the premier clinical and cost containment partner in the field of solid organ and bone marrow transplant centers. LifeSource manages more than 5,000 patients annually in their panel of 115 transplant centers and 400 affiliated transplant programs.
Pharmacy Benefits
Problem: International pharmacy solutions must take into consideration unique reimbursement processes, network access and cost. Many international patients find their prescription insurance coverage is not recognized by U.S. pharmacies, thus obligating patients to pay for medications at full retail cost. The burden of the cost and administrative process is an inconvenience for patients.
QHM Solution: QHM has partnered with CVS Caremark to provide patients who purchase medications in U.S. and Puerto Rico. CVS/Caremark can effectively manage costs and improve outcomes through it s pharmacy stores, mail order and specialty pharmacy divisions. For international payers that do not provide a pharmacy benefits members have access to QHM/CVS Caremark pharmacy discount programs.
New strategies of oncology risk management connect patients, physicians and payers while improving care and cost.
