The term Utilization Review can elicit different meanings depending on the vantage point of the person reading the word. It is a broad term that is used throughout when talking about Managed Care Cost Containment techniques. ICS believes that Utilization Review is best broken out into three distinct, but yet completely integrated processes, Prospective, Concurrent and Retrospective Utilization Review.
In this model, which is the traditional operational process of a medical provider sending in a request for treatment, diagnostic service and/or specialty referral prior to the services being rendered to the injured employee, ICS has pioneered many efficiencies and can confirm that it has one of the very few technologies that integrates the decision point outcomes from Prospective Utilization Review into a hard flag within the Medical Bill Review application, all done in real time. Medical services requiring pre-certification are reviewed by a pre-certification nurse/medical director as part of the utilization review program.
It is our belief that an aggressive and proactive telephonic case management program, where the Telephonic Nurse Case Manager is working with the providers, therapists, etc. on a regular basis, provides for a very effective utilization review services. During ongoing case management, the Telephonic Nurse Case Manager is aware of procedures, testing, therapy and ancillary services requested, and are in the best position to review and evaluate any necessary services on a timely basis.
It is during the Concurrent Utilization Review process that is typically incorporated into our Early Intervention Nurse Case Management process, that interaction with the injured employee regarding their current and future treatment plan that may identify the need for redirection of care.
ICS provides Retrospective Audit and Review on all complex medical bills. This review consists of reviewing all coding and the associated documentation to verify that the billing was submitted correctly and that the submitted documentation supports the services billed.
Augmenting the traditional Medical Bill Review adjudication process of securing savings via Contractual PPO discounts and Fee Schedule/UCR reductions, we have created comprehensive Retrospective Review Programs that are typically part of our overall Integrated Medical Management Program.
We strongly believe that the integration of the retrospective medical bill review process with the prospective utilization management process (supported with technology data exchange) facilitates the process of yielding the final reimbursement decision. As the relatedness of treatment to the underlying injury and determination of a treatment is fed into the nurse case management system, this information also becomes available to the individual in the bill review department that makes the final reimbursement decision.