Medical Management

     For Workers’ Compensation programs, our in-house staff of doctors, nurses and auditors provide a variety of medical management services through our wholly-owned subsidiary, MedReview Inc.

Optimal Synergy

     We created MedReview to provide customized utilization review and bill review services exclusively for AdminSure clients.  Due to its seamless integration with the claims administration process, MedReview enables us to be more efficient, to achieve better results, and to offer more flexibility than would otherwise be possible.

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. These professionals collaborate with our claims personnel on a daily basis. Furthermore, we carefully manage the entire utilization review process in accordance to the Labor Code and California Code of Regulations.

     Our utilization review has been awarded Workers’ Compensation Utilization Management Accreditation from Utilization Review Accreditation Commission (URAC).The URAC seal of approval signifies our continuous commitment for quality improvement.

     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.

Utilization Review Plan

Medical Bill Review

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

     Experienced MedReview 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 63%.

Physician Peer Review

     When appropriate, our claims personnel and nurses submit cases to
a panel of board certified specialists for physician peer review.  Also, our utilization review doctors often present alternatives to treating physicians rather than simply approve or reject treatment requests.  Frequently, this consultative process leads to a better outcome for the patient.

Nurse Case Management

     For severe or difficult cases, we draw upon a network of independent, professional nurse case managers who work closely with injured workers to ensure that timely and appropriate medical care is provided.  This not only reassures seriously injured claimants, it helps to reduce the duration, extent and cost of disability.

Pharmacy Benefit Management

     Prescription drugs are a significant part of a Workers’ Compensation medical budget.  We work with leading pharmacy benefit management firms to control costs by reducing physician dispensing, creating custom formularies, promoting high quality generics and reducing waste, fraud and abuse, especially in the dispensing of narcotics.

Medical Provider Networks

     Medical Provider Networks give an employer partial control over the choice of doctors and medical 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.