Systemedic's
VOCATIONAL AND REHABILITATION SVCS.

Systemedic's
ON-SITE CASE MGT.

Systemedic's
MEDICAL BILL REVIEW

PREAUTHORIZATION
Evonne Nusz, RN, CCM, Manager, Systemedic Review

The preauthorization resource has been required now in Arkansas for ten years (outpatient preauthorization was added in May, 2000) and—yes—it is working well in comp cost containment. It provides "a pause before treatment."

Tips & Benefits

• If you are in an MCO, take advantage of the preauth opportunity for steerage to a PPO facility (within the statewide True Blue if you are using Systemedic/USAble).

• The medical records obtained for the review can provide additional documentation for your file, clarify the injury, and often will help identify conditions and treatment unrelated to your claim.

• Use preauth as an opportunity to obtain a second surgical opinion about medical appropriateness and/or relatedness.

• Use it as an alert in your claims management that referral to a specialist or case manager is indicated.

• Use preauth to give you a window of opportunity for pre-treatment cost negotiations on costly new procedures that do not yet have fee schedule or PPO allowance controls in place (example: Orthotripsy).

• Have your preauthorization and bill review performed in the same location so that essential information can be shared—neither of these services should be reviewing a bill or a procedure in isolation.

RETURN TO WORK
Tom Strickland, M.Ed., Manager, Vocational Services

• Consider a voc consultant to help employer on job modification options. Use written or video Job Analysis for physician review for accurate communication; only one visit may be needed.

• Avoid working with only the phrase "light duty" as a RTW guide. Too ambiguous. Specific restrictions need to be clear for all parties to determine appropriate return-to-work options.

• If job placement is the basic rehab service being provided, let voc consultant provide claimant (assuming commitment and motivation) with practical job acquisition skills: where to find jobs, application completion, prepping for interview questions, job seeker video training, etc. He/she may not RTW until after settlement, but you have provided meaningful assistance.

• To maximize success of return-to-work with employer, have a voc consultant develop a Transitional Employment Plan. This is a time-specific (usually 4–8 weeks), personally developed plan—using a team approach: claimant, spouse (if indicated), employer/supervisor, physician, voc consultant/case manager. All parties understand vocational goal and all have specific responsibilities. If not successful, another RTW plan is immediately implemented.

ON-SITE CASE MANAGEMENT

• Carefully review physician documentation of "medical necessity" for durable medical equipment, particularly exercise equipment and/or motorized mobility devices that are advertised on national television. The documentation may have been prompted at patient/claimant's request, with little regard to:

  • Patient/claimant's ability to use equipment

  • Pre-existing/co-existing conditions that could be aggravated by use of the equipment

  • Potential for the equipment to provide little if any therapeutic benefit, return-to-work assistance, etc.

• Injured workers may have pre-existing diagnoses for which treatment/diagnostic tests are prescribed that would be similar or identical to treatment prescribed for the actual injury. Early in-depth evaluation of injury related treatment plan can help define compensable treatment and provide cues to allow appropriate separation of charges for unrelated treatment.

MEDICAL BILL REVIEW
Doney Williams, PD, Manager, Medical Bill Review

• Make sure you are getting a multi-level bill review. Systemedic provides three cost-containment possibilities on each bill reviewed: 1) the AWCC fee schedule (26% savings in 2003) 2) Nurse Review and 3) True Blue PPO combined, saved an additional 21%, for a total savings of 47%. Leave any of these three out, and you're spending money you didn't have to.

• The RVU allowance in the AWCC fee schedule for the surgeon, is not applicable to the facility fee for surgery charged by outpatient hospital, or ambulatory surgery center.

• Make sure you are paying the correct component on items such as Radiology. Hospital should be paid technical component, not total component.

• Relative Value Units (RVU's) from the national HHS table are updated at least annually, and sometimes quarterly. Make sure your bill review provider is staying on top of these regular revisions (outdated allowances can be too low or too high).

• Watch for very high pricing on pain pump solutions for implanted pumps. We have seen prices vary from $30 to $13,500 for one pump refill solution. "Ownership" and J-codes are two issues to be aware of in reviewing these bills.