SecureCare’s Clinical Review objective is to ensure all in-network clinics utilize an appropriate level of care for patients from a medical necessity standpoint. SecureCare does not determine the appropriateness of care by prior authorization. Instead, we provide oversight through retrospective data analysis.
A retrospective analysis of each payer’s historical claims data, combined with SecureCare’s knowledge of typical practice patterns for each profession by diagnosis, is utilized to develop clinical benchmarks. These are defined as a target for a clinic’s entire patient population by line of business, and when exceeded, initiates an in-depth medical record review. Benchmarks are not a per-patient cap, but a cumulative average of all patients seen during a 12-month period.
Clinics who remain within the set clinical benchmark may practice with minimal oversight. Clinics who exceed set clinical benchmarks are defined as outliers. Medical record reviews are performed on these clinics by licensed peers based on “Best Practice Standards” to confirm outlier status and develop recommendations for the clinic to become compliant.
Each month, SecureCare posts report cards in the Provider Portal. Report cards display key performance metrics for each clinic and provider as well as a comparison to the clinical benchmark(s) and your peers in the network.
Credentialing is a critical function allowing SecureCare to properly identify qualified providers to participate in our network. It ensures providers fully meet all established industry standards. Since being URAC accredited in 2012, SecureCare has credentialed thousands of conservative care providers.
Credentialing Verification Organization (CVO)
Since 2018, SecureCare has been a URAC accredited, and NCQA-compliant CVO. SecureCare is available to credential all provider-types. This process ensures all established industry standards are met.
Self-Funded Health Plans
As employers look to manage medical costs, many are turning to self-funded plans where the employer pays the medical expenses on behalf of their employees, and the insurance company administers the benefit program.
Today, most employers want to increase utilization of cost-effective conservative care. SecureCare’s elimination of fraud, waste and abuse through our robust clinical review program appeals to companies with self-funded health plans. This benefit lowers the cost for both employers and employees. Clinics receive proprietary guidelines and standards outlining SecureCare’s expectations to meet the needs of each patient based on medical necessity. SecureCare relies on in-depth data analysis and detailed medical record reviews to improve patient outcomes and reduce over-utilization.
Chiropractic Medicaid Expansion
In 2016, SecureCare and the Nebraska Chiropractic Physicians Association took action to pursue Medicaid expansion for chiropractic benefits in Nebraska. The process began by researching current benefits across the country which found 30 states had some level of coverage and twenty states had zero coverage. Eleven states had coverage exceeding Nebraska’s, which at that time included 12 annual Chiropractic Manipulative Therapy (CMT) visits for adults and 18 CMT visits per diagnosis for children. There was also coverage for x-rays and a small payment for the initial evaluation.
After initial meetings with state leaders, SecureCare developed an evidence-based presentation that included important topics related to the use of chiropractic services. Simultaneously, SecureCare began conversations with Nebraska State Senators regarding the expansion of chiropractic benefits.
Several years later a legislative bill was introduced, and the process moved forward. Legislative support was a major factor in expanding chiropractic Medicaid benefits for Nebraska. These now include the following:
- Medically necessary treatment for patients of all ages
- The following CPT codes are now covered:
- E/M: 99201, 99202, 99203, 99211, 99212, 99213
- Radiology: 72040, 72070, 72081, 72082, 72100
- CMT: 98940, 98941, 98942
- Therapy: 97012, 97014, 97032, 97035, 97110, 97112, 97140, 97530
In all, it took four years to complete this process. SecureCare is hopeful that the re-telling of our success will spur other states to take similar steps for expansion. SecureCare is happy to share our presentations, library of studies and give any guidance that may be needed. Further expansion in this area will only serve to benefit the entire chiropractic profession.
Network Performance Analysis
Upon a payer’s request, SecureCare will generate an “opportunity analysis” for physical medicine network management. This is accomplished by performing an in-depth review of historical claims data and delivering a specific and detailed assessment of potential savings and areas of concern.
SecureCare is committed to ongoing provider education as a means to improve the quality of care delivered in conservative care. We have multiple avenues of education enabling all providers to improve outcomes while delivering medically necessary care.