FOR MORE INFORMATION:

MANAGER Karen Miller
TELEPHONE   501.227.5553 or 800.822.2680

Liability Claims Services

Systemedic offers a variety of services to help you manage your liability claims and to facilitate settlement negotiations:

  • MEDICAL CASE MANAGEMENT — Our RN Field Case Managers coordinate medical care and facilitate a goal-directed recovery plan. We also provide Life Care Plans in catastrophic cases. Our specialist case managers can be available to provide expert testimony in brain injuries, spinal cord injuries, burns, and general rehabilitation and life care planning.
  • VOCATIONAL EVALUATION — We provide evaluation and opinion, based on a review of the medical records, depositions, and work history. You can also request assessments regarding education, training, or suitable employment opportunities in the labor market, when appropriate to the claim. Evaluations can include a vocational interview with the plaintiff and/or the former employer. Our counselors are experienced in depositions and court testimony.
  • PROFESSIONAL RETROSPECTIVE RN FILE REVIEWSystemedic’s professional file review service provides valuable assistance in evaluating your claims issues and moving toward settlement and closure. We offer two levels of RN file review, tailored to your claims needs:
    • Screening Level RN File Review: An experienced RN specialist performs a quick, high-level review of the medical records and, in a brief telephone consultation, summarizes medical treatment and points out any potential red flags, such as pre-existing conditions or potentially unrelated or unnecessary treatment. If indicated by initial findings, the RN recommends a formal, comprehensive file review.
    • Comprehensive RN File Review: Our nurse specialists perform an in-depth file review with a formal report that lists the chronological treatment history, assesses any pre-existing conditions, identifies medical care that potentially is unrelated or medically unnecessary, and provides an analysis of the medical bills to separate accident related from unrelated charges, with the medical rationale for noting any treatments or charges as being unrelated. We also note any important missing medical records needed prior to settlement, including pre-injury records that might provide information that could decrease the cost of the claim. We highlight any issues needing clarification, further research, or the need for a physician review to establish the presence of accident related bodily injury, and provide a definitive opinion regarding the medical necessity of treatment.
  • PHYSICIAN PEER REVIEW — We coordinate specialty-matched physician peer reviews to more authoritatively address accident relatedness of injuries and medically necessary treatment (see information box at right). A physician peer review is conducted by reviewing the medical file and any related records; the physician does not see or speak to the injured worker.
  • INDEPENDENT MEDICAL EVALUATIONS — Systemedic can coordinate an Independent Medical Evaluation (IME) by a qualified physician to address specific claims issues. An IME is conducted through an actual examination of the injured worker.
  • COST PROJECTIONS — To assist in reserving costs for an ongoing claim, or as an aid in evaluating settlement proposals, Systemedic can provide a cost projection of on-going or future medical treatment for an accident related diagnosis.

Physician Peer Review in Liability Claims

Systemedic’s RN specialists assist in, and coordinate obtaining an objective and comprehensive URAC accredited physician peer review, tailored to the specific issues of your claim. This service may be accessed either during the treatment process or after treatment has concluded (concurrent or retrospective review).

Common Issues Addressed in Peer Reviews

  • Accident related diagnoses
  • Unrelated conditions
  • Accident related aggravations of pre-existing conditions
  • Medical necessity and relatedness of treatment
  • Maximum Medical Improvement (MMI)
  • Potential future treatment
  • Temporary or permanent disability
  • Usual and customary charges

Benefits of Peer Reviews Coordinated by Systemedic:

  • We perform an initial organization of the medical records.
  • We identify pertinent missing documentation.
  • We assist in obtaining missing documentation.
  • We develop questions for the reviewing physician, specific to the claims issues of concern.
  • We select the appropriate physician specialty for the peer review.
  • We refer the file and our questions to a URAC accredited medical review organization, providing access to practicing physician reviewers nationwide (including chiropractors and dentists).
  • We screen the peer review report when it comes back for accuracy and completeness, and follow up with the reviewer if additional clarification is needed.
  • We prepare a billing analysis and separation of charges based on the peer review opinion.
  • We provide interpretation and clarification for the claims adjustor, if needed.

All the services described on this page are also available for workers’ compensation cases.