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CCMSI's MANAGED CARE PROGRAM.
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The medical cost component of workers' compensation claims continues to escalate at an alarming rate. In response to this trend, CCMSI has developed a managed care delivery strategy to maximize savings and more positively contribute to the employer's efforts of minimizing the total cost of risk.
In tandem with our best-in-class claims handling practices and supported by our proprietary risk management systems, our newly designed integrated managed care program, comp mc, will ensure that all components of the managed care process will interact smoothly and efficiently. The net result is a reduction in both medical costs and the duration of the employee's absence.
The pie chart displays the total comp mc savings for the fourth quarter of 2007. The client gross savings were 41% of the total dollars billed. (Updated on 1/09/08) Components of savings included are:
NEW COMP MC STUDY NOW AVAILABLE BELOW!
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CCMSI BILL REVIEW ANALYSIS BY STATE
SUMMER 2007 BENCHMARKING STUDY - POSTED AUG 2007
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Strategies and Techniques
- A mosaic approach to preferred provider networks;
- An Internet-based medical bill re-pricing process;
- Utilization Review and Utilization/Disability Management;
- WC Prescription Discount program;
- National diagnostic testing scheduling/discount network; and
- Specialty Bill Review (Ambulatory surgery centers, in-patient/out-patient hospital, high dollar professional fees and hospital bill audits).
Key Components
Provider Bill Review
Our provider bill review process is as comprehensive and efficient as any in the marketplace. Using the most robust and flexible software available in the industry today, it has the ability to:
- Upload fee schedule revisions for each state as they are released, thus insuring both regulatory compliance and maximum savings;
- Receive timely electronic updates of Ingenix, a nationally recognized geo database for usual and customary bill review; and
- Improve workflow processes by using Optical Character Recognition (OCR) and document management integration technology, thereby minimizing turnaround time.
This enabling technology permits us to offer our clients:
- The elimination of excessive charges;
- The elimination of duplicate charges;
- The identification of billing infractions; and
- The ability to write customized rules for each customer to identify and divert predefined bills for certain injury and/or procedures to a nurse case manager for review and challenge.
Following the review process, all provider bills, medical attachments, and Explanation of Review (EOR) images are integrated into our proprietary claims application ("Toolbar") where payment data is electronically uploaded to the system on a daily basis.
Preferred Provider Networks (PPO)
Our PPO strategy is unique in that we have access to numerous national, regional, and proprietary networks. Additionally, we have the ability to further customize each specific program by incorporating client negotiated provider discounts. This mosaic approach insures that our clients realize optimal network coverage that results in maximum savings. comp mc provides access to over 20 PPOs nationwide.
Diagnostics
CCMSI utilizes a national diagnostic discount/scheduling network for MRIs, CTs, EMGs, etc. With access to more than 3,200 facilities nationwide, CCMSI's comp mc clients are realizing an average savings of $785 per referral (based on 2005 calendar year data).
Specialty Bill Review
CCMSI also utilizes a specialty bill review service. This service is dedicated to helping workers' compensation, auto and health payers successfully reduce health care costs by combating providers' excessive billing practices. Robust data from more than 20 public and proprietary sources provides the legal, medical and financial bill analysis that ensures a jurisdiction-specific fair, reasonable and, most importantly, defensible re-pricing review.
Integrated Pharmacy Program
Prescription drug costs now account for 12% of the total medical costs of claims. Alarmingly, these costs are increasing at the rate of 15% per year, a rate faster than general medical inflation.
comp mc has an integrated pharmacy program linked directly to our bill review software, and proprietary claims software called comp RX. This allows us to capture "First Fills" and adjudicate pharmacy claims directly on line at the time of dispensing. Studies indicate the first fills account for 80% of all pharmacy costs; therefore, any successful program must capture this event. The comp RX pharmacy program ensures pricing below state fee schedule or usual and customary rates (UCR) and allows reports to reflect pharmacy costs as they relate to total medical expenditures.
Utilization Review
Our utilization review process is fully automated, user defined, and links prospective utilization and treatment control activities performed by the nurse or adjuster with the fully automated retrospective re-pricing done within the bill review software.
Utilization/Disability Management
CCMSI realizes that there is a direct correlation between proactive nurse case management and early return to work. Nurse involvement results in a decrease in medical costs and, can also positively impact the indemnity costs associated with the claim.
Whether our clients decide to use our proprietary nurse case management resources (available in select offices) or wish to employ a preferred partner, it is important that the nurse case manager is actively involved in the return to work process. Their ability to successfully interact with all interested parties, to establish and oversee a medically appropriate and cost effective treatment plan, and to provide instructional and educational support to the injured employee (when applicable), insures the realization of desired outcomes for everyone involved.
Our nurse case management objectives include:
- Fostering a team approach between our nurse case manager and the claims adjuster;
- Working together in developing an early return to work plan for the injured employee by obtaining the necessary functional job capability information from the treating physician and integrating the information with the employer's transitional job description;
- Where early return to work is not feasible, to help the employee achieve maximum medical improvement for future return to work in a full-duty capacity;
- In those situations where the employee is unlikely to return to work for their current employer, their role is to assist the injured employee in reaching maximum medical improvement, allowing the claims adjuster to recommend future case disposition to the employer;
- Monitoring provider utilization by comparing the frequency and duration of care with diagnosis specific treatment plans utilizing the nationally recognized Presley Reed Medical Disability Advisor guidelines; and
- Reviewing hospital admissions for the medical necessity of in-patient care.
We know each client may have specific needs based on their historical loss experience and/or their specific organizational culture. We encourage all our clients to work with their CCMSI Account Manager in designing a disability program that will help them achieve their specific goals.
Analysis and Saving Reports
CCMSI realizes that our clients require objective and definitive data in order to not only measure the success of their managed care program, but also to fine tune it for even better performance.
We offer our clients on-line access to their results via the Internet.
Using the secured portal on our website, our clients can choose any number of report(s) from our report library. These reports can be used to gauge any number of variables.
Summary
It is difficult to find a balance between the services our clients demand and the cost-savings they require to keep a competitive edge. There is an affordable solution-one with the ability to combine the services our clients want with a flexible pricing structure.
With comp mc our clients achieve:
- A multi-faceted approach to achieving maximum medical cost savings;
- An individualized PPO hierarchy that reflects their provider utilization pattern;
- The ability to view real-time managed care outcomes for any chosen time frame; and
- Independent objective review of managed care savings data.
If you would like more information on how to reduce your medical costs and the duration of the employee's absence through comp mc, please call Sharon Elliott at 800-252-5059, ext. 1268 or e-mail her at selliott@ccmsi.com.
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Alabama Bill Review Analysis