Early identification of patients creates higher quality of care and lower costs

Kaiser Permanente manages 12.6million member/patients annually.  Many patients were being admitted to out-of-network emergency rooms and accumulating high claim costs.

We built a call center that required emergency rooms to confirm eligibility and benefit approvals.  Once on the call, our clinical staff would gather the clinical disposition of the patient, and if the patient was stable for transfer, we would arrange for medical transportation back to an in-network hospital for care.

I partnered with the City of Los Angeles Fire Department (911 responders) and created an "On-Scene Assessment Program".  If the Kaiser patient was determined to be medically stable for transfer, the fire department would transfer the patient from the scene to the closest Kaiser Permanente designated hospital.

If the patient required admission to an out-of-network hospital, we provided 24/7 virtual physician rounding to assess the patient's care until stable for transfer to the Kaiser Permanente hospital to complete their care and treatment.

The integrated program, from early identification through to inpatient physician oversight, saved more than $235M annually in unnecessary claims costs and reducing the medical loss ratio.  The community emergency room and providers received peer-to-peer consultations from experienced emergency room physicians and nurses.  If the subsequent claim matched the agreed upon services, the out-of-network organization received accelerated claims payment.