Workers Compensation Management

A well designed and monitored managed care arrangement will undoubtedly produce cost savings to the employer. Aggressive claims management, coupled with well designed loss control programs go hand in hand with controlling costs.

The key components in any worker's compensation program are:

• Case Management
• Pre-Certification
• Utilization Review
• Quality-Assurance Monitoring
• Increased Regulatary Reporting

Managed care's impact on the quality of care a worker receives is a critical issue. Just managing through fee discounts alone is not enough. Restricting medical care can be dangerous and may not be cost effective. In many cases, an intensive approach to treating injuries saves both medical and wage-loss costs.

The results of using Managed Care Concepts, Inc. and Worker's Compensation Management programs are:

• Faster claims closure
• Reduction in disability days
• Average cost per claim lower than the national average
  

First Call

"First Call" is a claim management reporting system which directs employees towards care at the initial point of the claim. The system is convenient, fast, and easy to use for both the employer and employee.

Purpose

• Get employee back to work
• Pro-Active Case Management
• Direction to network providers
• Employer/Employee calls toll-free "first call" number
• Demographics of injury/illness are obtained by registered nurse
• Referral is made to appropriate network provider

Features

• Communication
• Registered Nurses directing management of claims pro-actively
• Quality of care
• In-network referral management
• Utilization Management
  • pre-certification
  • outpatient
  • worker's compensation
  • psychiatric/substance abuse

Benefits

• Savings to employer
  • reduced claim modifiers
  • earlier closing of case files
  • employee returns to work sooner
  • discounted claims
  • prevention of lawsuits
• Case Management Linkage
• Guide employee to appropriate site for care
• Geographical Convenience

Implementation

Injury/Illness

• Employee sustains workplace injury
• Employee reports injury to employer
• Employee manifests symptoms of illness, is diagnosed, or surgery is recommended

Case Management

• Registered nurses initiate management of claim and early intervention
  
• Certification of acceptable treatment plan
  • medical outcome expectations
  • practice protocols
  • utilization criteria
    
• Notification of claims payer of treatment plan (compensability or medical benefit payments are determined by the payer).
  
• All referrals to specialists hospitals, second opinions, home health care, rehabilitation, etc. are coordinated and approved by "First Call" R.N.s.
  
• "First Call" manages the claim for its entire duration monitoring adherence to the treatment plan and accepted medical protocols
• Concurrent review to assess maximum medical improvement
  
• Pre-certification is required for:
  • inpatient admissions
  • all surgeries
  • procedures greater than $1,000.00
  • second opinions
  • all "non-emergency" related services for worker's compensation