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Everyone needs help now and again. That goes for patients, doctors, insurance companies and employers. PMG provides that help through the use of proactive management tools and speedy response. Our medical oversight programs are designed to identify problems early on so that medical treatment issues can be addressed at the right level and at the right time to make a positive difference. |
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PMG works closely with its clients to exercise what we call aggressive medical care coordination.
The idea is simple: get the patient to the right doctor for the right treatment right away.
Most commonly called Utilization Management or UM, the actual process is anything but simple
and requires the dedicated efforts of many professionals working
closely with the same set of marching orders.
PMG equips its clients and physicians with process flows for route of care, selected treatment
guidelines and problem resolution. That way,
when a patient enters the system,
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everyone knows what to expect and what is expected of them.
As a general rule, treatment plans, specialist referrals, special diagnostic tests and surgeries
are coordinated by case managers or adjusters and approved by key physicians in the PMG Network who
provide very specific medical oversight services for the plan. When a patient's treatment is running
smoothly, which it usually does, these oversight physicians work in the background to ensure that adjusters,
employers, case managers and others understand what is transpiring from a medical standpoint so that they can
make the necessary arrangements for resources, funds and other required support.
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When questions about the methods or direction of a patient's medical treatment arise, it is the responsibility
of the oversight physician to review the file and work with the treating physician(s) to confirm or redirect
the plan of care. This process speaks to the essence of utilization management in a direct and efficient manner,
without pitting nurse case managers against doctors in decisions regarding efficacy of care.
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PMG encourages its clients to use nurse case managers to assist doctors,
adjusters, employers and patients in dealing with non-routine medical care.
PMG establishes a protocol with the client that determines when it is appropriate
and necessary to bring nurse case management to a file. Once the threshold for
involvement is crossed, a staff nurse is assigned to assist the care givers and
adjusters in coordinating and managing a patient's care. Of equal importance,
the case manager also is charged
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with working with the patient to promote his or her understanding of,
and compliance with, the treatment plan.
Nothing can replace the necessary confidence that each patient must have in their doctor's
opinions and methods of care. However, nurse case managers can be
invaluable and highly cost-effective in smoothing the treatment process,
solving routine problems, and educating patients in the large and small
points regarding their rehabilitation and care.
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Utilization Review is a process through which medical oversight personnel attempt to judge,
or pre-judge, the necessity and appropriateness of a patient's medical care. Through its
bill review and other record-keeping processes, PMG regularly provides detailed treatment
history information to oversight physicians and nurse case managers who are specifically
charged with comparing actual treatments to treatment guidelines and to established community standards of care.
A Utilization Review can take many forms, from informal record review to a detailed analysis conducted by a panel of doctors, nurses
and risk management personnel.
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Regardless of the level
of review, the goal is always the same: to help our doctors treat our patients in a manner
consistent with accepted standards and appropriate to the patient and the situation.
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