Medical Cost Containment - Utilization of Services

BILL REVIEWS:

Bills received for processing are forwarded to the managed care organization (MCO) your company has selected.

The MCO then enters the bill into its system. The usual practice is to review the bills according to the States' Fee Schedule, the Usual & Customary rates for non-fee schedule states. It is then determined if a PPO was used and if the bill is to be repriced for that specific discount.

Bills are reviewed at that time for proper coding, bundling or unbundling, and medical necessity.

Most MCOs request that the bills include the patient's social security number, the claim number, and the provider ID number. This protects your company from paying duplicate bills.

Depending on whether a bill is faxed, mailed or sent electronically, the turn-around time should be within three days after the MCO has received the bill unless an unusual problem is determined. At that point, communications should be made with your company to so advise.

INDEPENDENT MEDICAL EXAMINATION:

You, the adjuster or the nurse case manager with your authority, make a referral. An IME Board certified physician is chosen to match the area of expertise and geographical location. An appointment is scheduled and documentation is provided with instructions to the provider, the claimant, you and/or the adjuster, based on your preference. An immediate follow up to the appointment is conducted to discuss the attendance and anticipated report timeframes.

The report is received and immediately sent to you and the adjuster.

EARLY INTERVENTION AND TRIAGE:

Immediate notice is given to the MCO Registered Nurse. The RN then searches the database to determine the best facility and medical provider to assist in administering care to the injured worker. The RN becomes involved with a local nurse case manager and insures that the patient is receiving the best possible care and that timely reports are being sent to the claims adjuster and your company. This process is best used in catastrophic cases such as burns, paralysis and closed head injuries.

MEDICAL ONLY AND IN-HOUSE CLAIMS

By initiating a contract with a managed care organization (MCO), we have made it possible for savings not only through those claims reported to the TPA, but also claims handled at each insured's individual offices.

You can bulk mail on a weekly basis or fax individual bills, depending on the amount of time required to pay the bills, and still receive appropriate discount.

It is recommended that a provider be utilized with each bill.

Some companies have established independent relationships with local MCOs and this practice is encouraged to be continued. If at any time, a company would prefer the contracted MCO's services, this can be accomplished by notifying your Claims Consultant.

Services provided by the MCO are listed under the appropriate tab.