Medical Cost Containment - Managed Care Organizations

PREFERRED PROVIDER ORGANIZATION (PPO):

Through development efforts nationally, a preferred provider network is in 48 states. This provides the opportunity to generate significant hospital and physician discounts while enhancing the quality of care.

The advocacy program allows patients to be channeled at the onset of an injury/illness, to the most appropriate provider within the network. Bills will be adjusted automatically to state fee schedules or usual and customary, while simultaneously applying the PPO discount.

Through the use of the Internet, determination of local PPOs becomes very simplistic and allows field personnel to determine doctors and clinics during the pre-job phase.

BILL REVIEW SERVICES:

The practice of reviewing or auditing medical bills against Fee Schedules, or in non-fee schedule states, against Usual and Customary reimbursement levels. These services can reduce medical costs from 10%-40% and are available in all 50 states.

The key benefits are:

• Duplicate bill detection

• Professional RN/Doctor review services

• Ability to review all Fee Schedule and U&C states' provider bills

• Analysis includes a "service to date" summary by provider

• Identifies treatment/charges not related to the compensable injury

• Identifies the CPT.4 code bundling, fragmented billings, upcoding, etc.

• Able to review all types of medical bills, including pharmacy, DME, vision, dental, ambulance, anesthesia, radiology, etc.

• True and accurate analysis of claims costs

HOSPITAL LINE ITEM BILL REVIEW:

This is a clinically-based cost containment service, which reviews the hospital bill (both the UB92 and the line item bill) and begins within the first 24 hours, with a nurse reviewing the bill and identifying:

• Appropriateness of line item for diagnosis and procedure

• Potential duplication

• Errors

• Unbundling

• Inappropriate billing patterns

• Usual & Customary overcharges

EARLY INTERVENTION AND TRIAGE:

Case management has consistently emphasized the concept of early involvement in an injury or illness to minimize medical costs and achieve the best recovery. Early intervention results in better medical care, lower claims costs, and greater perceived benefits of service by all participants. Coordination of this effort with the insured/claimant, medical provider, and claims administrator in a cooperative and collaborative manner can make a significant difference in the success of the program. It allows for access to a "real time" information exchange and the development of an immediate medical treatment plan.

The ability to find the best medical provider for the specific need within the PPO when possible.

PRE-CERTIFICATION;

This is a review service, which verifies the medical necessity of proposed hospital admissions, and determines the appropriate length of stay.

UTILIZATION REVIEWS:

The evaluation of a proposed treatment plan for appropriateness, care setting and duration of care. A utilization review can identify those claims in which medical case management would be beneficial.

CASE MANGEMENT:

The establishment, coordination, and control of the treatment, direction, support and assistance given to the injured worker from injury through medical stability, to maximum medical improvement and release for return to work. It usually includes plan development and implementation and aggressive follow through.

INDEPENDENT MEDICAL EXAMINATION;

Provides objective medical evaluations for clients who need accurate, comprehensive, and prompt assessments of medical questions concerning the prognosis of the injured worker.

VOCATIONAL REHABILITATION SERVICES:

The assistance in determining the ability of the injured worker to re-enter the workplace. The services of vocational rehabilitation are various and can be used in an unbundled or integrated basis. The process includes:

• Job analysis and placement

• Expert testimony

• Job development

• ADA compliance

• Labor market survey

• Vocational assessment

• Job seeking skills

• SSDI benefit procurement

• Early return to work program

• Transferable skills analysis

PEER REVIEW:

A review of medical records, performed by a person or persons of equal or greater qualifications as the provider being reviewed, for medical necessity of care, the appropriate duration of treatment, and/or causation of the symptoms.