Managed Care Services
How can you be sure that the specific medical care recommended or provided by a healthcare provider for an injured worker is appropriate and necessary? Seeing that every injured worker's needs are unique, it's more important than ever to have expert help at your side to determine whether recommended (or already provided) medical treatment is appropriate.
That's where Utilization Review Services can be so important to you. Our medical professionals carefully examine each service, reviewing whether the diagnostic tests, treatment, or medication are supported by established evidence-based criteria.
Our Utilization Review Services include Prospective, Concurrent, and Retrospective Review to optimize treatment of a worker's injuries at any stage of the claim. We help insurers comply with individually mandated state and URAC guidelines and timetables for Utilization Review, as well as state reporting of Utilization Review Services in the states where this is required.
Through our integration with UR Decision Manager™, our UR decisions are automatically enforced in the SmartAdvisor bill review system. This helps improve the financial investment made in utilization review.
Utilization Review is a critical component in any medical cost containment strategy. For this reason, our staff of medical professionals evaluates the necessity of medical care to determine that the right medical treatment is provided at the right time, for the best possible cost and outcome for each injured worker. Our staff works closely with healthcare providers to determine the appropriateness and quality of medical care being requested for the injured worker. Each member of our staff is supported by advanced analytical software that allows them to keep our clients up-to-date on the services receiving approval or those recommended to be denied.
Depending on the situation, our professionally licensed utilization review (UR) staff can perform any or all of the following services where allowed or mandated by state laws:
- UR—Adjuster Authorization
Subset of Utilization Review based on the client's predetermined list of services. Primarily handled by support staff with nurse consultation if needed. Determination letter sent and data captured for auditing purposes.
- UR—First Level
A pre-certification of treatment not requiring physician review. The first level review is completed by a licensed health care professional, who evaluates the requested service and all submitted documentation. The licensed professional may certify requests or forward the request to Second Level-Physician Review.
- UR—Second Level-Physician Review
Utilized in conjuction with First Level (UR) when treatment is not within guidelines or a higher level of review is needed by a physician.
Telephonic Case Management
Managing the timely rehabilitation and return to work of an injured worker is a team effort. The art (and savings to you) is in coordinating the efforts of the healthcare providers, the insurance adjuster, the employer, and the injured worker. This will assure that medically appropriate care is given, that the injured worker is properly motivated to work on his/her recovery, that costs are managed effectively, and that the injured worker safely returns to work.
Get the help of an experienced professional to successfully accomplish this difficult coordinated effort, someone who can act as a patient advocate and also help protect the interests of the injured worker, the insurance carrier, and the employer. They can coordinate the treatment plan prescribed by the physician, promote resolution of the claim, target evidence of fraudulent activity, minimize claims costs effectively, and assure the best return-to-work strategy. One of the qualified, medical professionals on the Telephonic Case Management Services Team is the answer.
Telephonic Case Management
is a critical component in the success of any
return-to-work program. Many advantages can be realized by using Mitchell Workers’ Compensation Solutions Telephonic Case Management to:
- Maintain documentation of scheduled contact with each injured worker to promote timely return to work
- Protect the interests of employers by detecting an injured worker who may be exhibiting destructive or fraudulent behavior patterns
- Appropriateness of the physicians
- Monitor the progress of the injured worker and alert the insurance adjuster, employer and healthcare providers of any barriers or setbacks that could impede a timely return to work
- Defense of your decisions with evidence-based, nationally recognized criteria that comply with regulatory standards of care
- Reduce claims costs by assuring physicians provide appropriate medical care for the industrial injury
February 26, 2013
Mitchell releases predictions for trends related to cloud computing and big data analytics that could affect the insurance industry throughout 2013
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November 27, 2012
Though claimants often have a choice when it comes to medical providers, charges for treating with out-of-network providers can be substantially higher than charges submitted by doctors in preferred provider networks…
Full Article >>