Spotlight: Deborah Ault, RN, President, Ault International Medical Management

About Deborah Ault

Deborah Ault has been a Registered Nurse for 27 years (We lovingly refer to her as “Nurse Deb”). Before getting into Care Management, her bedside nursing experience included ER, ICU, Doctor’s Office, Home Health, and Telephone Triage. Now she is the President of Ault International Medical Management (aka AIMM). Her team of Nurses and Doctors help patients navigate both the health delivery and the health insurance systems. By ensuring that the right patients are getting the right care, at the right time, in the right place, at the right price AIMM creates win-win-win situations (patient, provider, and plan all win!).

About Ault International Medical Management

Ault International Medical Management, LLC, headquartered in Bucyrus, Ohio, provides care management solutions with an innovative approach that changes the way medical care is delivered to patients and significantly improves the quality of health care they receive. Comprehensive utilization, care and disease management programs benefit patients, clients and strategic partners by effectively controlling overall claims costs. For more information, call 419-562-3451 or visit https://www.aim-m.com/.

 

Medical Travel Today (MTT):What distinguishes your company in the marketplace?

Deborah Ault (DA): We bill ourselves as an independent carve out concierge patient advocacy based medical management firm.

We work with self-funded health plans and those that are looking to become self-funded in the near future.

One of our most recent product additions was a fully insured to self-funded bridge program.  We see groups that are wanting to make that move, but maybe don’t have the data or have some fear or trepidation about making the change.  We incorporate special strategies to help them open up their options.

Often, especially if they are fully insured and not really a large group, they run into some barriers and don’t know if they are healthy enough to make the change.

These are some typical questions:  Is the timing is right?  Should we look at level funding?  Should we look at straight funded?  Do we go into a captive?  Can we get any information to help us make that decision?

This product has grown very rapidly because the shift from fully-funded to self-funded is surely underway.

MTT: Where are your clients located?

DA:  We are headquartered in Columbus, OH.  We have clients in 41 states and the last I knew, we were up to about eight countries.

What’s Interesting on the international side is that global companies will have people who are in the US and need medical care. Or the companies will send employees to the US to get medical care — which is surprising because of all the studies that say maybe we are not the highest quality of care in the world.

The bottom line:  everybody wants us.

MTT: So, your employer clients are worldwide?

DA:  Yes.

MTTAnd your providers are worldwide, as well?

DA:  Yes, with the exception of one program that we do for hospitals with healthcare providers who are sponsoring their own health plan.

We are not a PPO, we’re not a network, and we are none of those ancillary, bolt-on cost containment strategy components.

We are just the team of nurses and doctors that do the utilization management, care management, disease management and wellness management piece.

We work on behalf of the employer who is sponsoring the health plan, and then we come alongside those individual patients — one by one — at the point of needing care.  We telephonically guide them through both the health delivery system and health plan system.

We help a patient pick doctors, and we will look first to see if they have a PPO network.  Many plans have open access to provides so they can go anywhere.

Here are some of the issues if the patient has a PPO:

  • Who are the providers in your PPO?
  • Are they capable of doing what you need?
  • Who is the best quality provider within that list?

If you have something that is rare and unusual, such as the need for a Whipple procedure, the mortality rate is high:  a very high percentage of patients die in the OR for that procedure.  But if it is needed, data tells us that the patient should go to the one of five experts in the US that are expert at performing the procedure.

Most likely, this surgeon is not in the individual’s PPO network, so we come alongside the patient and help them navigate both the health delivery side and the health plan side.  Simultaneously, we make sure they are getting the highest quality of care in the most cost-effective way possible.

If there is a barrier and they need a provider that’s not covered by their plan or not in their network, we try to see if there is any way to make changes in the plan design.  Are there opportunities for exceptions?

What is the stop loss carrier going to think about it if this patient goes to UCLA for a medical procedure that he can’t get anywhere else?

If the provider is not in network, can we negotiate with that provider.

Marrying up that clinical and financial piece on an individual patient level is really what our specialty is.

MTT: If a provider hospital outside the country wanted to be on your radar, how would they go about that?

DA:  They all do it different ways.

Some of them send me messages on LinkedIn – which is quite a fun adventure.

Generally speaking, providers like Health City/Cayman Islands have some different ways to go about this.

Usually, it’s through one of our preferred partners. We work with a select group of benefit consultants and advisors across the country and often one of those entities will say, “Have you heard of this provider?”

We will go through a vetting process with that provider to find out their credentials.  What are their specialties?  What are the costs involved and what services do they offer?

As patients come in, we ask if this person could benefit from traveling to the Cayman Islands, for example. Then, going back to their group, if the person’s not in that health plan, we look at the plan design.

Looking at the group, we inquire if the health plan design supports this option.  What we see happening is as the medical travel option becomes more attractive, a lot of stop-loss carriers intervene and say they won’t cover international claims.

Navigating that whole piece prospectively, rather than reactively, becomes more and more critical.

Before a group says, “Oh yes, fly down to the Cayman’s, we’ll cover it, it’s so much cheaper and makes perfect sense,” we alert them to the directives of their stop loss carrier.

The key is to determine if they will run into problems six months from now when the stop loss claims come in.

MTT: How do you see the medical travel market going?  Do you think it’s going to increase?  Do you think people are going to travel for care?

DA:  Patients are generally receptive to traveling for care.

I have been amazed by that, to be quite honest with you. As a nurse, we always thought so.

I grew up in a small town and the nearest hospital was only 30 minutes away.  The nearest level one trauma center was only an hour away.

We wanted a hospital nearby, but many didn’t offer oncology services and you had to travel for care.

MTTWhere did you grow up?

DA:  Bucyrus, Ohio.

So, when medical travel first started I wondered if people would go.  It turns out they do travel, especially with a lot of the education that has happened.

Groups that are self-funded have done a really good job in getting their employees to understand that this is a different kind of health insurance available and that we all share in the cost.  This has raised receptivity to travel for treatment programs.

As a matter of fact, we now talk to a patient about how; we got the request for this surgery, but before we complete the authorization, we make sure that the patient knows about the bundled surgery pricing option and the availability of a medical travel option.

We inform patients and advise them that it would be in their best interest — both medically and financially — to weigh their options.

One hundred percent of the time they say, “Yes, absolutely. I totally forgot about that option and thanks for reminding me.”

MTT That’s exactly the kind of conversation that we hear from employers.  Patients don’t realize that they have that option.

DA: So embedding that option at the point care when precertification is required would be appropriate.

It’s really an ancillary bolt on.  There may be multiple, great solutions such an EAP, bundled surgical pricing, a preferred network for imaging, or programs for domestic or international travel.

All these options are great opportunities for the patient and the employers.

The biggest challenge is that when you look at your data and see that you paid for ten hysterectomies – and considered the savings if all of them went through the bundled surgery pricing — we would save a tremendous amount of money.

Unfortunately, only two people may have opted into this option.

The only way to get that optimal utilization for all of those ancillary cost containment bolt on solutions is to embed them into the precertification functionality.

When a patient walks into a doctor’s office, what is the first thing that the doctor’s office asks them for?

MTTYour insurance card.

DA:  Yes.

The next thing they do is call your insurance company to make sure you do have insurance, are you effective & eligible on the plan. Is the patient eligible for care coverage and do they understand precertification requirements?

We’ve got providers pretty much up to speed that if you don’t get it pre-authorized, you’re going to run into problems with payment. Now they will call and seek pre-certification.

The challenge becomes that you’ve got a lot of the industry norm which is to look at medical necessity –but skip looking at appropriateness.  All they look at it is if this person is scheduled for a total knee replacement and it meets the criteria for medical necessity, they authorize it.

But they look only at right patient, right care.  They may even look at right time, but what they skip over is right place and right price.

If the place of service is not processed through the surgery bundling pricing solution, then it may not be the right place and it may not be the right price.

When you’re doing precertification and gathering all the clinical data, you know it’s going to get certified because it meets medical necessity.

But the appropriate approach is to go through that extra path to make sure this is the right place and the right price for the group.

MTTAnd you’re the one who does that?

DA:  Yes.  Embedding that into precertification is what makes our model so successful.

MTTThat is really phenomenal.  And you are a nurse?

DA:  Yes.

MTTHow long has it been since you’ve done direct patient care nursing?

DA:  Oh gosh, it’s been over 25 years since I’ve done direct patient care.  It’s been awhile.

MTTYes, but you have a great background to bring to this.

DA:  I like nurses and doctors being the primary point of contact.

I know there are vendors out there that use non-nurses, I’ve seen that in the industry.  I’m sure they have their reasons for doing so, but nurses are still the most trusted profession in the world.

There’s something to be said for having a nurse who looks at things a little bit differently. This happens all the time –– because we teach our patients that for any health or insurance question to call the nurse or doctor.

They may call in and say they need help in finding an in-network podiatrist.  Okay great, I can help you with that, why do you want to see a podiatrist?  “My knee hurts.”  Well wait a minute, podiatry is feet, not knees – why would you want to see a podiatrist?

If you just call your PPO network and say you need help in finding a podiatrist, they’re going to give you the names of three podiatrists and then you’ll spend time and energy and take a half day off work to go see a podiatrist and discover that they don’t treat knees.

MTTRight! That’s a great example.

DA:  That’s why I like having nurses at the forefront.

And nurses pick up on other things.  We develop relationships with our patients and we see their claims data.  Somebody calls in and says, “I need help in finding an orthopedic surgeon because I need a total knee replacement.  I’ve already been seen by my primary care doctor, he recommended this guy but I don’t know him and do I need authorization?”

Often, when we pull up the history of that patient, we learn that they are diabetic and that introduces a whole different recuperation period than just a regular total whole knee.

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