Stop Loss Large Case Management

Large-case management (LCM) helps control costs associated with the care of patients with long-term or catastrophic illnesses or injuries while coordinating appropriate treatment for the patient. Our oversight helps ensure utilization of appropriate discounts and case-management programs. We do not designate a particular case-management firm, but may make vendor suggestions.

Our goal is to support you and/or your LCM vendor in managing large claims.

Our case manager can assist with:

• Referral to specialty vendors for complex cases such as transplants, neonates and renal failure.
• Negotiation of discounts
• Literature on diagnosis, drugs and treatment
• Information on ancillary care (e.g., home health care, DME, etc.)

When LCM begins, our case manager periodically monitors the treatment to determine appropriateness and cost effectiveness.

The TPA's role in LCM

As administrator of the employer's self-funded medical plan, the TPA:

• Identifies potentially large claims or potential case-management situations
• Notifies Mutual of Omaha about claims that may reach the specific deductible
• Initiates LCM early, while a degree of control is possible
• Recognizes when the case requires a level of expertise beyond what your staff or your case management vendor can supply

Identifying potentially large claims

It is critical to spot large claims as soon as possible. After treatment has begun, it is difficult to alter a course of treatment or achieve savings.

The TPA and/or LCM vendor may identify the need for LCM when:

• A benefit verification call is received
• Care is precertified
• Diagnosis information on a claim is reviewed
• A PBM provides disease management information

What is a large claim?

Large claims often result from diagnostic and medical conditions with the potential to become catastrophic/chronic or high-dollar.

Case types and diagnoses that often result in large claims

Notifying us early about potentially large claims or potential case management situations.

As soon as you become aware of a potentially large claim, complete the Specific 50% Notice and mail, fax, or e-mail it to us. The Specific 50% Notice must also be submitted whenever charges exceed 50% of the specific deductible.

LCM reimbursement

Initiate the case-management process as soon as the potential for its effectiveness is identified.

We reimburse to the extent case-management charges/fees and claims exceed the specific deductible. Other case management reimbursement arrangements are subject to our approval. All case-management charges/fees must be reported separately to us.

Neonatal care review

We continually assess health-care programs and services that can help you provide quality outcomes and manage costs for clients and plan members. One of those programs, CareAssist, specializes in care management and forensic neonatal claim audit services.

CareAssist has brought value to TPAs and self-funded group health plans on complex, clinically challenging cases involving care review of newborns. It has facilitated positive outcomes and reduced costs based on case-specific care plans and forensic reviews.

CareAssist can coordinate their activities with your utilization review and case-management staff. We encourage you to consider CareAssist, or other vendors providing similar services, as a resource for your neonatal cases.

Interlink Transplant Network

Mutual of Omaha has contracted with Interlink Health Services, Inc. to make transplant related services available to our TPA partners. Interlink is one of the nations leading outcome-based transplant networks. By using the Interlink Network, you are assured of accredited facilities, quality service, cost effectiveness and the best possible outcomes.

Learn more about Interlink Transplant Network

Contact Us

For more information about our LCM processes or TPA Stop Loss products, submit a request.