Missouri Health Plan Improves Efficiency by Outsourcing Guideline Development

SEATTLE, April 17, 2014 /PRNewswire/ -- Missouri-based Cox HealthPlans recently adopted clinical guidelines from MCG (formerly Milliman Care Guidelines) to improve management of outpatient and home care.

"We're looking at outpatient care more closely and moving toward prior authorization for scans and other high-cost procedures," said Daniel O'Connell, Cox HealthPlans' Director of Medical Management. "Initially, that made some providers nervous. Learning that our decisions would be supported with strong evidence-based literature put them at ease."

Previously, Cox HealthPlans had developed its own ambulatory and home care guidelines.

"Creating and maintaining guidelines in-house is a headache and labor intensive," said O'Connell. "It takes a good deal of staff time to do the initial research, and performing annual updates is an ongoing burden. We pride ourselves on running an administratively lean organization, so we're always looking for opportunities to control costs while maintaining and even improving quality. Outsourcing guideline development allowed us to do both."

O'Connell estimates that MCG content replaces 90% of medical policies that had been maintained internally, driving down administrative expenses.

Steve Hearon, Medical Department Manager for Cox HealthPlans, says that implementing MCG's ambulatory and home care guidance has improved confidence in the organization's utilization management process.

"With home-grown determination policies, there's always the potential for gaps," said Hearon. "We especially found that to be the case with home care. MCG's guidelines are clear cut and straightforward – they capture most exceptions. That means decreased need for second level reviews. As you can imagine, our medical director is a big supporter. And when he does have to review a case, he's tickled that he can just click a hyperlink to navigate to the underlying evidence."

In addition to Ambulatory Care and Home Care, Cox HealthPlans continues to license MCG guidelines that cover care in the acute, recovery facility, and behavioral health settings.

About Cox HealthPlans
Cox HealthPlans, an affiliate of CoxHealth, provides insurance solutions for over 45,000 members across Missouri and throughout the nation. Locally owned and managed in Springfield, Mo., Cox HealthPlans employs more than 85 staff members with special expertise in Medical Management, Claims Processing, Member Services, Finance, Underwriting, Information Technology, and Marketing. Their dedication and knowledgebase provide the highest quality customer service, accurate and timely claims payment, and expert medical management members have come to expect from a leader in the health care industry. For more information, please visit www.coxhealthplans.com (http://www.coxhealthplans.com).

About MCG
MCG, formerly Milliman Care Guidelines and now part of the Hearst Health network, independently develops and produces evidence-based clinical guidelines and software used by more than 2,200 clients, including 1,200 hospitals and 8 of the 10 largest U.S. health plans. Updated annually by an experienced team of clinicians, the care guidelines support the care management of a majority of Americans. For more information, visit www.careguidelines.com (http://www.careguidelines.com).

The Hearst Health network also includes FDB (First Databank), Zynx Health, and Homecare Homebase. The mission of the Hearst Health network is to help guide the most important care moments by delivering vital information into the hands of everyone who touches a person's health journey. To learn more about the Hearst Health network, please read the Hearst press release.

Media Contact
Nancy Narraway
MCG
Tel +1 206 389 5405
[email protected] 

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SOURCE MCG