June 22, 2009

Medical Cost Containment Strategy Is Vital to Claims Management

Well-managed companies help themselves by planning carefully for all contingencies. Because of the potential for loss, medical cost containment strategies should be high on everyone's list. Here's a handy outline to help you develop or review your own strategy.

Medical Direction - A well-designed and documented Medical Plan establishes in advance the authorized primary care providers, pre-negotiated rates and agreed upon treatment protocols. We have sample plans to guide you, and we're always available to help you with this important task.

Care of Injured Employees - The most important thing is making certain any employees injured on the job get quick, proper care. Follow these steps when authorizing medical treatment:

• Confirm that treatment is related to the injury
• Determine the need for pre-certification of diagnostic tests
• Authorize referrals to specialists from primary care/treating doctor

Case Management - Teamwork is the key to successful case management, due to the number of interested parties. You must include the internal nurse/case manager's recommendations as well as those of outside case managers. Independent medical opinions and peer reviews must also be factored in. Always maintain your focus on treating the employee successfully and returning him or her to work quickly.

Adjuster Oversight - The patient, physician/provider and employer/adjuster maintain a three-way, ongoing discussion from the time of injury until the employee has recovered. You must coordinate case management to assure employee compliance and progress with the medical plan of care. This includes coordinating the employee's return to work, and setting aside some reserve for any future medical care that may be required.

Review Medical Charges - This is not difficult, but is vitally important to the integrity of your strategy. You must review the medical charges regularly and consistently to ensure they are in fact related to the treatment provided. Sometimes mix ups happen. Also ensure the services are by an authorized provider, as identified in your Medical Plan. Physician peer review helps verify that all treatment is reasonable and necessary.

Bill Review/Audit - This step alone will save money and encourage plan compliance: always have an outside company audit all medical bills. Good auditors can find errors you might not know about. They always look for compliance with usual and customary treatment protocols, and they look for preferred provider savings and discounts.

For more information, please contact Susan Hopper, the Combined Group's Director of Medical Review toll-free at 800-275-3193, ext. 768, or email Susan at Shopper@combinedgroup.com.