Medical Management

     For Workers’ Compensation programs, our in-house staff of doctors, nurses and auditors provide a variety of medical management services in close coordination with our claims administration activities.

Medical Bill Review

     Under California law, Workers’ Compensation medical charges are capped by the Official Medical Fee Schedule (OMFS).

     Experienced medical bill auditors use specialized bill review software to scrutinize every line of every medical bill for duplicate or unrelated charges and conformance to fee schedule.  The software includes expert system logic to ferret out such anomalies as multiple, initial office exams.  It also ties into several Preferred Provider Organization (PPO) networks that yield further discounts below fee schedule.

     Savings from bill review are substantial.  They range anywhere from 35% to 87% with an overall average of 61%.

Utilization Review

     Workers' Compensation medical treatment in California is regulated by the Medical Treatment Utilization Schedule (MTUS).

     In fact, this schedule, which includes treatment protocols from various sources such as the American College of Occupational and Environmental Medicine (ACOEM) and the Official Disability Guidelines (ODG), is the basis for mandatory utilization review in California.

     Recognizing the importance of utilization review, we have assembled an exceptional team of medical professionals, consisting of registered nurses and licensed physicians, to apply the concepts of evidence-based medicine.  These professionals are on-staff, in-house, working shoulder-to-shoulder with our claims personnel on a daily basis.

     Our professional approach to utilization review has had a substantial impact on eliminating many of the questionable medical practices and abuses that have plagued the Workers’ Compensation system.

Physician Peer Review

     In special circumstances, our claims personnel and nurses submit cases to our medical director for referral to physician peer review.  Also, our utilization review doctors frequently present alternatives to treating physicians rather than simply approve or reject treatment requests.  On many occasions, this consultative process has resulted in a speedier or better recovery for the patient.

Nurse Case Management

     For severe or complex cases, our claims personnel draw upon a network of independent, professional nurse case managers who work closely with claimants to ensure that appropriate medical care is provided in a timely manner.  This personal touch is reassuring to seriously injured claimants and helps to reduce the duration, extent and cost of disability.

Medical Provider Networks

     Medical Provider Networks offer an employer the opportunity to exercise some control over the choice of doctors and treatment facilities in Workers’ Compensation cases.  AdminSure has access to established networks, which can be customized, using carve-outs.  Or, we can build a network from scratch.  Customizing an existing network is generally more cost-effective than building one from scratch.