|
|
 |
 |
|
|
|
|
Medical treatments cost employers hundreds of millions of dollars every
year. Utilization Review programs are vital and necessary tools used in
preventing the inappropriate, excessive or medically unnecessary
treatment of an injured worker. Costs keep escalating at an alarming
pace and without a properly designed and well integrated management
tool in place it can lead to a financial disaster.
California law has opened the door for workers' compensation reform and
has finally provided some positive regulations that will benefit all
parties in the workers' compensation system. The introduction of the
American College of Occupational and Environmental Medicine (ACOEM)
guidelines provides payors a standardized methodology to review the
care provided to an injured worker against the evidence of what works
the best for that particular injury.
PrimeCare Health Services Group Inc.
Utilization Review Services are designed to integrate with both the
bill review and claims payment systems. Our team of professionals
consist of a medical director, registered nurses, occupational
physician specialists including orthopedists, physiatrists,
chiropractors, psychologists, internists and physical therapists.
When a request for a medical service is received, either
telephonically, by mail, fax or email, our utilization review
specialists will provide medically appropriate decisions regarding
treatment, based upon ACOEM guidelines or other evidence based criteria
where ACOEM doesn't apply. In many cases our professionals will offer
alternatives for care where necessary, all in a timely manner for both
the doctor and the employee.
PrimeCare Health Services Group Inc. provides all levels of Utilization Review services required, including:
- Pre-certification of medical service requests;
Hospital Inpatient, Outpatient and Surgical services;
Ambulatory Surgery Center Services
Physical Medicine Services (chiropractic, physical therapy, etc.)
Durable Medical Equipment requests
- Concurrent Review
Continuous follow-up of services in progress, monitoring frequency, duration and the appropriateness of care
- Retrospective Review
Review of services performed that were not authorized or went beyond
the approved limits, by ACOEM guidelines, UR staff or state law.
Appropriateness of treatment provided will be analyzed by a peer
reviewer or medical reviewer and will provide a response to the
treating physician.
|
|
|
|
|
