Care vs. Cost: How are decisions made

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Today Neighborhood Health Partnership members are actively involved in making their own health care decisions. Whether asking a doctor about a certain drug advertised on television or requesting a specific treatment, our members participate in the “partnership” that is NHP.

NHP has established a Utilization Management program with the primary goal of offering a health care delivery system that promotes the achievement of positive outcomes in the most cost-effective manner, without compromising the quality of care we offer and you expect. This program allows us to continue to be competitive in the healthcare market, and at the same time provide you with an affordable premium and health plan.

Underutilization of health care and services poses a risk to the health and safety of NHP members. Underutilization could mean our members were not receiving proper preventative care needed to stay healthy. It could also lead to limited member access to out-patient/inpatient care and inappropriate emergency room use.

NHP monitors the utilization practices of its practitioners and providers, looking to detect and correct potential underutilization.

NHP does not use incentives that encourage barriers to care and/or service, or that reward inappropriate restriction of care. Rather NHP encourages appropriate utilization while discouraging any underutilization.

To this end, NHP distributes a statement describing the basis for NHP’s utilization management decision-making to all of our practitioners, providers, employees, and members. With this statement NHP affirms that:

• Utilization management decision-making is based only on appropriateness of care and services and existence of coverage.
  
• NHP does not reward practitioners or other individuals conducting utilization review for issuing denials of coverage of service or care.
  
• No incentives are offered to encourage decisions that might result in underutilization.

It is important to us that you understand our commitment in ensuring that our members receive the best and most appropriate care possible.

If you would like more information on the procedures NHP uses to control utilization of medical services and expenditures, please call Member Services Monday through Friday from 8am to 6pm at 305-715-2500 or 1-800-354-0222 (TTY for the hearing impaired at 305-715-2322).