Services for Health Plans

WholeHealth Living offers a variety of customized Integrative Health Solutions emphasizing the delivery of high-quality care, with appropriate cost containment to improve clinical outcomes, create savings, and enhance member satisfaction.

• Practitioner Network Management
• Provider Engagement
• Utilization Management
• Claims Processing Services

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Practitioner Network Management

WholeHealth Living will identify, build, credential, and maintain a network of licensed integrative health practitioners. Development of this network will be supported by our clinical team, composed of practitioners representing multiple practice specialties including chiropractic, acupuncture, massage therapy, naturopathy, physical therapy, and occupational therapy. WholeHealth Living will identify potential practitioner candidates for contracting first by working with licensing entities responsible for the health plan’s market geography.

• Recruitment and Contracting – WholeHealth Living has an experienced team of recruiters who are dedicated to growing our Integrative Health Network and are well-educated in practitioner value proposition, network contracting, and benefit requirements. Through an in-depth analysis, the Network Recruitment Team works together to identify quality practitioners to recruit and contract into the Integrative Health Network.
• Credentialing – WholeHealth Living Inc. Credentialing Department has been a NCQA certified Credential Verification Organization (CVO) since 2000. Delegating to an organization that is NCQA certified, like WholeHealth Living, Inc. Credentialing Department, helps streamline the delegation oversight process.
  
  WholeHealth Living, Inc. Credentialing Department has received certification from NCQA for the following credentials verification services license to practice, education and training, work history, malpractice claims history, Medicaid/Medicare Sanctions, CVO application and attestation content, practitioner application processing and ongoing monitoring.
• Practitioner Engagement and Retention – The WholeHealth Living practitioner engagement team provides a proactive approach to the management of our practitioner network by onboarding and educating new practitioners, creating new communications and engagement initiatives to stay in touch and understand practitioner satisfaction, and conducting network audits. This team helps retain the quality network of practitioners, as well as ensure WholeHealth Living can continue providing practitioners with the education and resources they need.

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Provider Engagement

At WholeHealth Living, we understand the importance of educating the broader medical community on the importance of integrating nonpharmacologic options like acupuncture, massage therapy and chiropractic into patient care. In fact, a recent survey conducted by Tivity Health’s Consumer Research Team reports 4 out 5 respondents are more likely to utilize integrative health therapies should their provider recommend them to do so.¹

Unfortunately, the typical treatment pathway is to prescribe opioids, order expensive imaging, and refer out for a surgical consult because this is what providers are trained to do. Our team will work in partnership with a health plan’s provider network to ensure they are educated on the efficacy of these types of therapies and begin recommending them to their patients. Providers will become comfortable referring to our network of practitioners because they know they are qualified, licensed, and credentialed.

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Utilization Management

Our Utilization Management approach ensures the delivery of clinically appropriate care grounded in evidence-based best practices, supported by data analytics, practitioner engagement, and education.

WholeHealth Living, Inc. has been accredited with Utilization Review Accreditation Commission (URAC) for Health Utilization Management (HUM) since 1997 and with National Committee for Quality Assurance (NCQA) for Utilization Management since 2014. We are licensed to conduct utilization management in all states where this is a requirement.

For utilization the of integrative health services, WholeHealth Living employs a flexible, multi-pronged approach to benefit utilization:

• Reauthorization at a specific visit threshold
• Post-service, pre-payment claims review
• A quality management and consensus approach

Utilization Management helps control overspend on unnecessary integrative health services. It is estimated that healthcare waste accounts for approximately 25% of total healthcare spending.² An OIG audit revealed 82% of Medicare chiropractic claims submitted did not meet medical necessity.³ WholeHealth Living’s clients have seen a 3.6 to 5.7 ROI when applying Utilization Management services to chiropractic benefit.⁴

Our comprehensive clinical decision support pathways, claims screening, and care pathway technology ensure members who utilize their benefits receive care that is clinically indicated and medically necessary. Leveraging WholeHealth Living’s proprietary Rapid Response System®, all authorization requests are pre-screened using clinical decision support pathways which consider the patient history, diagnosis, co-morbidities, and other factors in the clinical profile. Our Rapid Response System provides immediate decisions on more than 60% of the approved authorization requests.⁵

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Claims Processing Services

As a part of the WholeHealth Living suite of services, we have full claims processing capabilities that include claims repricing and/or claims payment. Claims are electronically sent to the health plan to apply the member benefit.

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1. Tivity Health Consumer Research, September 2019. “Perceptions Of Complimentary & Alternative Medicine Among the SilverSneakers Population”.
2. One-quarter of U.S. Healthcare Spending Deemed Wasteful | AACC.org
3. Audit Says Medicare Overpaid $358 Million for Unnecessary Chiropractic Services – JOHN HOWLEY, ESQ. (johnhowleyesq.com)
4. WholeHealth Living Business Analytics ROI Analysis 2019-2021
5. WholeHealth Living Utilization Management Rapid Response System Audit Analysis