Medical Management

Medical Management Programs

Community Case Management

Community Case Management is a medical management program utilized to help BIDPO physicians achieve the performance targets included in the contracts negotiated with BCBSMA, HPHC, and THP, and to provide high quality, cost efficient care to their patients. Nurse case managers work with BIDPO PCPs (assigned by pod) and their patients who are covered under managed care plans. Community nurse case managers focus particularly on complex, high risk patients who would benefit from this approach to care.

A listing of BIDPO Community Nurse Case Managers and the physicians to whom they are assigned can be found at http://home.caregroup.org/bidpo_case_mgr/search.asp

Case Manager Activities include:

  • Work with pod leaders, individual PCPs, and practice staff to determine the pod’s needs in meeting their pay for performance incentives, and use that as a basis for creating implementable actions to help them achieve the targets.
  • Promote high quality health for patients by ensuring they receive the appropriate screening and testing as defined by the HEDIS measures.
  • Regularly review data as it relates to the individual and pod’s performance on the HEDIS measures.
  • Verify data that is received from the payor for accuracy via electronic or paper record audit.
  • Outreach to patients by telephone or mail for the purpose of providing support, education, and to ensure the patient has the required testing.
  • Develop a documentation system to track outreach to patients and outcomes of testing.
  • Perform any required audits by the payor.
  • Serve as a resource to new PCPs and office staff in the use of electronic technologies such as NEHEN Express and Anvita imaging CDS.
  • Provide individual telephonic care management to selected complex, high risk patients via a web-based software application.