When looking at medical care and cost containment, there are several things a company may want to include in its Account Servicing Instructions (ASI) to facilitate the involvement of a physician reviewer.
- Request the Right to See Records
First, the company should reserve the right to request copies of selected medical records be transferred to and reviewed by a physician reviewer who is selected and retained by the company before scheduling of IMEs. (Independent Medical Review).(WCxKit)
In some cases, the physician reviewer sends a cover letter to the IME physician to establish appropriate parameters and ask pointed medical questions for the physician to consider during the course of the IME.
- Bills should be Paid in a Timely Manner
The payment of medical bills within 14 days is very important as is the timing of referrals of medical bills to an audit vendor (selected by the insured) to review for fee schedule, customary compliance, duplication and over utilization.
The level of bills to be audited should be predetermined and copies of all explanation of benefit (EOB) forms are forwarded to the company upon receipt.
The designated bill review company examines all hospital bills (inpatient and outpatient) without regard to dollar amount, and all hospital admissions should be precertified by the company’s selected utilization review company.
- You May Refer Some Cases to Medical Case Management
The company also requires referral of all lost-time and complex medical cases to those in charge of medical disability management, senior nurse reviewers, within 24 hours, and it should receive copies of all medical disability management reports.
Functional capacity evaluations are recommended in all cases prior to IMEs, unless the physician reviewer recommends otherwise. As soon as maximum medical improvement is achieved, the claimant is to be referred for vocational rehabilitation if not back to work.
- Your Company Should Conduct File Audits
On the procedural side, the company conducts file audits of all claims every three months in local carrier offices. The carrier provides the entire file for this review focusing on claim resolution strategies.
Incredibly, one carrier came to a file audit without the files; bringing only file summaries and medical report summaries. These are not adequate, especially because our MD was there to review the medical portion of the files. Lesson learned…
- Consider Deeply Your Litigated Claims
All litigated claims should be considered for alternative dispute resolution. Several vendors nationwide are available to perform this service. There should be specific, detailed discovery request TEMPLATES ready to send to all outside counsel, for each step of the litigation from assignment to settlement – your expectations should be put into writing.
The company retains the right to request copies of all file materials, including medical reports, necessary for business purposes. It is important the insured also retain the option to change, revise or amend the ASI with 30-days written notice and to have reasonable requests accommodated.
Risk managers should request their insurers provide ASI in a clear, narrative format, rather than in an unreadable computer printout.
- Read your Agreement Before Changing Carriers
Many companies, in a practice known as “carrier hopping,” change their insurance carriers frequently because they are not receiving a high enough level of claims service.
It is suggested before risk managers change insurance carriers due to dissatisfaction they re-read their ASI to see if their company’s expectations are clearly delineated.
Most insurance carriers are prepared to rise to the level of service that demanded, but many companies simply do not know what to request or how to use the ASI document to convey expectations.(WCxKit)
It is imperative companies striving to manage claims know they already have a tool with which they can address this critical aspect of business.
There are many ways to review your WC management. Discover six oft overlooked methods #WorkersComp.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. See www.LowerWC.com for more information. Contact: RShafer@ReduceYourWorkersComp.com or 860-553-6604.
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