Utilization Review

Services

Bill Review

Catastrophic Case
Management


Ergonomics

Field Case Management

Functional Capacity Evaluation

Future Medical & Rx Review

Life Care Planning

Non-Occupational Absence Management


Peer Review

Peer-to-Peer Intervention

Qualified Rehabilitation Consulting (QRC)

Return-to-Work – Interactive Search Process

Technology

Telephonic Case Management

Task Assignments

Utilization Review


Excel Managed Care & Disability Services (Excel) specializes in Utilization Review services. Our unique program is made up of URAC approved peer review physicians and medical professionals who have designed a program to meet the specific needs of our clients by offering the following services:

1. Peer Review Physicians (PRP)

Like Specialty

Excel peer review physician panel are URAC approved and feature 1-2 physicians of each specialty to ensure a like peer-to-peer evaluation. Many URO’s have a limited panel of specialists and cannot provide the medical community with a like specialist. The result is a report that may not be accepted by the physician or create expensive penalties assessed at the time of an audit.

Communication

Peer reviewers play an active role in the decision process by reaching out to the requesting physician in the form of a phone call. This allows both parties to discuss treatment options before reaching a decision and provides an opportunity to educate the medical community to the Utilization Review process.

Evidence Based Medicine

ACOEM/MTUS and other evidence based resources are always used to support UR medical decisions. Excel peer review reports incorporate ACOEM/MTUS findings but we do not stop there as ACOEM/MTUS does not always address type and scope of treatment request. Because of this, Excel uses the following evidence based medicine to support each decision:

  1. ODG
  2. National Guidelines Clearinghouse
  3. Medline Search of the National Library of Medicine
  4. Cochrane Systematic Review Databases
  5. American College of Orthopedic Surgeons
  6. American Society of Interventional Pain Physician Guidelines
  7. Philadelphia Panel Guidelines for Musculoskeletal Disorders
  8. Orthopedic Fracture Rehabilitation Guidelines
  9. International Chiropractic Society Guidelines,
  10. Colorado Workers Compensation National Guidelines
  11. ACOEM
  12. MTUS

Medical Director

Our Medical Director provides daily interaction with our clients through peer reviews and conversations with the medical community. At no cost, the Medical Director will provide training to the claims team 1-2 times a year. Training sessions educate the adjusters with current medical case studies and Q&A session.

2. Physician Profiling

Reports are available to clients that will identify physicians that either over prescribe or consistently request treatment that exceeds MTUS/ACOEM Guidelines. These identified physicians can be trained individually to have a better understanding of MTUS/ACOEM Guidelines and reporting requirements. If the “bad” behavior continues, the client would have the option of removing physicians from their approved panel.

3. Location

Excel staff and peer review physicians are located in California. Our local presence allows for the highest level of service to our California clients.

4. Utilization Review Process

Ease of Referral

We provide the client with a simple referral process and offer several options that include phone, fax, e-mail, or web referral.

We also offer a service that accepts referrals directly from the requesting physician. Only medical request pre-approved by the client will be accepted by Excel then summarized and e-mailed to the adjuster. Excel intake coordinator then begins the task of securing missing medical reports from the requesting physician before forwarding to the UR nurse. This service saves the adjuster time and increases productivity. Also, medical providers calling the claims office to request authorization can be directed by the adjuster to call Excel toll free number. Excel will review the pre-cert list before accepting the referral and begin the intake process.

Both types of referrals are appreciated by the claims adjuster as it reduces the time and work associated with making a referral.

Nurses

Excel skilled nursing team is knowledgeable with MTUS/ACOEM Guidelines. The nurse’s role is to make timely UR decisions, send appropriate letters to all parties and make every effort to work with the physician by modifying treatment requests that exceeds MTUS/ACOEM Guidelines. Excel nurses make great efforts to communication with the requesting physician as we believe an open line of communication shortens the approval process and reduces the number of peer reviews.

Cost Saving Reports

Cost saving reports must be easy to read and understand. Numbers presented should document real savings and not best case scenarios. Savings should be fluid by adapting to changes in UR decisions from the previous month. Monthly reports should document all relevant information outlined by the DWC and be ready to present to state auditors within 30 days from receipt of notice.

5. Security Features

Excel security features are designed to meet HIPPA and SAS 70 security measures. In addition, a disaster recovery plan is made available upon request.

6. Communicating with Nurse Field Case Managers

Because Excel provides clients with Field Nurse Case Managers (FNCM) and Utilization Review services, information is seamlessly shared between the two nurses. This means the UR process is expedited and the FNCM is assured of appropriate, timely approval of medical treatment.

7. Charges

Fees are simple to understand and priced to reflect the level of services provided. Peer Reviews should only be used when the nurse is unable to certify or modify treatment.

8. Data Base and Technology

Technology is crucial to a successful UR program. Excel IT team has designed and implemented eManagedCare,™. This technology allows clients to access monthly reports, cost savings, and UR status through an internet web-based program. Special features allow management and adjusters to access the following information:

  • Real Time Access
  • Ad Hoc Reports
  • Scanned Medical Documents
  • Online Letters
  • Online Peer Review Reports
  • RN notes
     
     
Case Management Services Utilization Review Non-Occ Absence Management eManagedCare
Ergonomics Rx Reviews Bill Review RTW Services
   

   

 

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