Clinical governance
Clinical governance comes before savings.
CareCostDown is designed as a clinically governed surgical cost-management pathway, not a medical travel referral service.
For self-funded employers, a global Center of Excellence pathway must be selective, documented, and clinically appropriate. The goal is not to send more people overseas. The goal is to identify when a structured Center of Excellence pathway may be appropriate, when it is not appropriate, and how to manage the process with clinical discipline.
Program view
Surgical spend pathway
Savings
30-50%
Governance
Clinical review
Reporting
Case-level
Employer reporting snapshot
12
Eligible cases
3
Clinical exclusions
Modeled
Pilot savings
Governance principles
A conservative framework for elective surgical pathways.
Every case should be evaluated through clinical, operational, and member-readiness criteria.
- Clinical suitability before financial savings
- Voluntary member participation
- Procedure-specific eligibility and exclusion criteria
- Documented review and decision process
- Continuity planning before and after surgery
The program is intended for selected, non-emergency elective procedures. It is not designed for urgent care, unstable medical conditions, or cases where travel would create inappropriate risk.
Physician-led review
Physician-led review for every eligible case.
Clinical review is used to evaluate whether a member may be appropriate for the pathway before coordination proceeds.
CareCostDown's pathway includes physician-led review of relevant medical information, procedure category, risk factors, and care setting suitability. This review helps determine whether the member may continue through the program, should obtain additional documentation, or should remain within a domestic care pathway.
- Proposed procedure category and available business context
- Prior non-sensitive treatment summary when provided through an authorized workflow
- Comorbidities and travel-related risk factors
- Surgical complexity
- Recovery and follow-up requirements
- Member readiness and informed preference
- Whether the overseas pathway is clinically appropriate for the case
Medical necessity assessment
Medical necessity context and appropriateness are reviewed before pathway approval.
The program is not intended to encourage unnecessary procedures or redirect inappropriate cases.
CareCostDown supports a documentation-based review of whether available records support the proposed elective procedure and whether the case appears appropriate for a Center of Excellence pathway. This review does not determine plan coverage and does not replace the member's treating clinicians.
- Review of available documentation supporting the proposed procedure
- Review of procedure category and eligibility context where applicable
- Confirmation that the procedure is planned and non-emergency
- Review of prior treatment history
- Consideration of alternative care pathways
- Identification of exclusions or elevated-risk factors
Center of Excellence criteria
Center of Excellence selection is based on standards, not destination.
Facilities and physicians should be reviewed against defined quality, capability, and operational criteria.
CareCostDown evaluates potential Center of Excellence facilities using a structured criteria framework. Geography alone does not determine suitability. The program is designed to work only with centers that can meet defined standards for selected procedure categories.
- Review of any available facility accreditation or local regulatory standing
- Surgeon qualifications and specialty experience
- Procedure-specific case volume
- Infection prevention and patient safety protocols
- Anesthesia and perioperative care capabilities
- Documentation availability and coordination process
- Escalation protocols for complications or unexpected events
- Commercial transparency and bundled pricing readiness
Documentation standards
A governed pathway requires clear documentation.
Documentation supports clinical review, member understanding, care coordination, and employer reporting.
CareCostDown uses documentation standards to keep the pathway consistent and auditable. The documentation process is designed to support appropriate decision-making without exposing employers to unnecessary clinical details.
- Member eligibility confirmation
- Consent and participation acknowledgment
- Documentation required for eligibility review
- Physician review notes or outcome category
- Program inclusion or exclusion decision
- Center of Excellence referral packet
- Discharge documentation
- Post-operative handoff notes
- Employer-level reporting outputs
Complication and escalation planning
Risk planning is built before travel, not after a problem occurs.
Every pathway should include defined escalation expectations for clinical issues, travel events, and post-procedure concerns.
Elective surgery always carries risk. A responsible global pathway must plan for complications, exclusions, emergency scenarios, and continuity needs before the case proceeds.
- Pre-travel risk screening
- Identification of high-risk exclusions
- Center of Excellence escalation contacts
- Local emergency care planning during the care episode
- Clear communication procedures for unexpected events
- Criteria for delaying or cancelling participation
- Return-home planning if recovery changes
- Post-operative concern escalation process
Post-operative continuity of care
The pathway does not end when the procedure is complete.
Post-operative continuity is essential for member safety, confidence, and employer trust.
CareCostDown supports continuity planning before the member travels and after the member returns home. The goal is to reduce gaps in communication, documentation, and follow-up.
- Discharge summary collection
- Procedure documentation and operative notes where available
- Post-operative care instructions
- Medication and wound-care information
- Physical therapy or rehabilitation planning when relevant
- Communication with domestic providers when authorized
- Follow-up check-ins
- Escalation process for concerns after return
Data privacy and documentation handling
Clinical information should be handled with role-based discipline.
Employers need program reporting, not unnecessary access to employee medical records.
CareCostDown's operating model separates clinical documentation from employer-facing performance reporting. Medical information used for eligibility review, coordination, and continuity should be handled according to applicable privacy requirements, contractual arrangements, and authorized use.
- Collect only information needed for program review and coordination
- Use consent-based documentation flows
- Limit employer access to unnecessary clinical detail
- Maintain role-based access to sensitive information
- Use secure transmission and storage practices
- Define data responsibilities in implementation agreements
- Separate identifiable clinical records from aggregate reporting when appropriate
Employee consent
Participation must be voluntary and informed.
Employees should understand the pathway, alternatives, risks, logistics, and their right not to participate.
CareCostDown is designed as a voluntary program. Members should never be told that overseas care is required. They should receive clear information about eligibility, clinical review, travel requirements, care coordination, potential risks, and alternatives.
- Plain-language program explanation
- Voluntary participation acknowledgment
- Authorization for records review and coordination
- Explanation of travel and recovery expectations
- Discussion of exclusions and case review outcomes
- Financial incentive explanation, if applicable
- Confirmation that the member may decline participation
Employer reporting
Employer reporting focuses on program performance.
Finance, HR, brokers, TPAs, carriers, and plan administrators need clear reporting without unnecessary clinical exposure.
CareCostDown provides employer-facing reporting designed to support program oversight, savings review, and implementation decisions. Reporting should be appropriate to the employer's role and avoid disclosing unnecessary member-level medical information.
- Eligible case volume
- Referral and inquiry activity
- Clinical review outcomes by category
- Completed procedures
- Estimated and realized savings
- Participation rate
- Program cost and incentive summary
- Member experience feedback
- Exclusions or declined cases by general category
- Operational issues and escalation summaries
Governance FAQ
Clinical governance questions employers ask first.
Is CareCostDown a direct-to-consumer travel referral service?+
No. CareCostDown is positioned as a clinically governed surgical cost-management pathway for self-funded employers. The program includes physician-led review, eligibility criteria, Center of Excellence standards, care coordination, and employer reporting.
Does every interested employee qualify?+
No. Participation is selective. A member may be excluded based on medical history, travel risk, procedure complexity, incomplete documentation, or other clinical and operational factors.
Who decides whether a case is appropriate?+
Cases are reviewed through physician-led clinical criteria and program governance standards. The member's own treating clinicians remain central to individual medical decision-making.
What procedures are included?+
The initial focus is selected high-cost elective procedures such as knee replacement, with additional categories reviewed based on clinical suitability, Center of Excellence readiness, and employer savings potential.
How are potential Center of Excellence facilities evaluated?+
Evaluation should be based on facility standards, surgeon qualifications, case volume, safety protocols, documentation readiness, communication capability, escalation planning, and procedure-specific fit.
What happens if a complication occurs?+
The program should define escalation contacts, local care pathways, communication procedures, and return-home continuity planning before the case proceeds. Elective surgery risk cannot be eliminated, but it can be planned for responsibly.
Does the employer receive employee medical records?+
Employer reporting should focus on program activity, savings, and performance. Clinical documentation should be limited to authorized parties with a role-based need to know.
Are savings guaranteed?+
No. Savings depend on procedure category, employer claims history, plan design, member eligibility, participation rate, program costs, and Center of Excellence availability.
Evaluate the pathway through a clinical governance lens.
Before launching a pilot, CareCostDown helps employers and evaluating organizations review procedure fit, eligibility criteria, documentation needs, privacy boundaries, and risk controls.