A guide to nurse-led claims management

With health insurance remaining one of the most significant of employee benefits, the business drive to reduce premiums, even when claims are rising, is higher than ever on the business agenda.

Credible cost control solutions are few and far between but some within the industry have succeeded in developing effective initiatives. The concept of nurse-led claims management (we call it Managed Care), for example, which originally hails from the US, describes techniques employed to control the cost of health benefits provision and to improve quality of care.

For PMI Health Group, this means a nurse-led case management service for its clients that are offering health insurance schemes to staff.

What does case management involve?

Where case management services are employed in the US, case managers working for health insurers coordinate claims and patient care. This can mean overseeing referrals to specialists and negotiating rates with providers that are not a part of a plan’s network.

In the UK, case management can mean helping an employee make a choice between private and NHS treatment.

PMI Health Group’s Managed Care service is both an employee healthcare advice and claims management service with qualified nurses giving expert advice and support on any healthcare related matter via a dedicated helpline.

Businesses that use this service have their own team of named nurses on hand to deal with all employee health concerns. The nurses’ deal with medical claims for them, so employees do not have to liaise with faceless insurers, and they’ll also organise the most suitable care.

NHS or private?

Many assume that private healthcare will always be the preferred option, but this may not always be the case.

Where private healthcare is indeed more appropriate, Managed Care nurses will negotiate with the insurer to cover the costs of a private consultation and treatment, including physiotherapy and rehabilitation, to get employees back to health as soon as possible.

Sometimes, however, the NHS can be more appropriate than private healthcare for treating injuries or illnesses. For example: 

  • If a patient has a critical or acute condition, NHS facilities are usually better equipped than a private hospital as 24 hour observation and expert support are on hand.
  • A particular NHS hospital may also have a leading specialist in the required field.
  • If an employee is claiming on behalf of one of their children, a specially designed NHS children’s ward is usually more appropriate than an isolated room in a private hospital.
  • Patients accepting NHS care under a private healthcare policy are also eligible for generous financial incentives (around £100 for each night spent in hospital).

A combination of NHS and private facilities can also be used to the patient’s benefit, using the private sector for testing, for example, and the NHS for treatment.

The business benefits

A Managed Care service can pay for itself many times over by reducing in-house HR administration time and stabilising insurance premiums.

In addition, as claims costs are controlled, for some companies, fewer resources need to be tied up in risk funds.

Discover more about PMI Health Group’s Managed Care service and how it has helped construction giant Vinci realise claims savings worth thousands of pounds.