Medical and Pharmacy Cost Containment Services
Services designed to provide quality, cost-effective care.

Medical Bill Review
CareWorks USA’s medical bill review systems assess bills for accuracy and duplication, as well as jurisdictional specific requirements.

Our system automatically re-prices bills to the lesser of the billed charges, state fee schedule, usual and customary reimbursement (UCR) or Preferred Provider Organization (PPO) network negotiated fee.

Multiple system edits detect inappropriate billing practices such as unbundling, upcoding and duplicate procedures. Checks for relatedness of billed procedures, diagnoses and prior authorization are also performed.

Bills can be flagged for utilization review or audit by a nurse, based on clinical criteria or billed charges.

Medical bills are processed within state required timelines. CareWorks USA can provide check-cutting services in addition to review and re-pricing of all medical bills.

PPO Network
CareWorks USA offers a comprehensive PPO network strategy for your program that ensures quality of care while controlling costs.

Our network strategy provides employers with access to credentialed medical providers who deliver quality, cost-effective treatment at rates typically below a state-mandated fee schedule or usual and customary reimbursement (UCR).

CareWorks USA has arrangements with multiple PPO networks to meet your needs. Our network partners have direct contracts with medical providers who typically treat occupational and non-occupational injuries. These providers understand the importance of prompt reports, compliance with medical management protocols and returning employees to work as soon as medically appropriate.

Our network partners have established credentialing, re-credentialing and quality assurance requirements for their members that support industry best practices.

Online access enables you to search for medical providers by geography, specialty and name. Work site postings of network providers can also be provided. Employers can nominate providers for inclusion in a network arrangement.

Our networks are integrated with our early intervention and telephonic case management services. Where appropriate, our nurses channel employees to network providers.

In addition, CareWorks can provide consulting services to develop customized, location-specific networks of occupational health providers trained in disability management and return-to-work practices.

Pharmacy Benefit Manager (PBM)
CareWorks USA partners with a national Pharmacy Benefits Manager (PBM) that offers one of the industry’s most comprehensive pharmacy solutions.

Our network includes more than 64,000 major pharmacy chains and independent pharmacies. Our PBM program provides point of sale (POS) adjudication that ensures medications are appropriate and related to a claim. First-fill and mail order programs are also provided.

Our PBM program includes:

• Electronic download of claim eligibility information.
• Online and call center eligibility systems.
• Ability to capture first fill immediately after an injury, allowing for a 30-day supply of medication with no out-of-pocket expenses for the employee.
• Point-of-Service (POS) edits for eligibility, prior authorization and utilization review that meet jurisdictional requirements.
• POS edits that check for unrelated medications, duplicate drugs, drug-to-drug interactions, early and unauthorized refills and generic substitutions.
• Ability to identify claims with long-term medications appropriate for mail order program.
• Reduced prescription fee through the PBM network.
• Electronic download of pharmacy bill data from the PBM to CareWorks USA’s systems.
• Retrospective Drug Utilization Review (DUR) program.
• Employee educational materials.
• Cost savings and DUR reports.

In addition, we offer a Prescription Drug Review (PDR) program that includes prior authorization of initial requests for medications and concurrent peer review of ongoing medications.

New prescriptions that are flagged by the PBM at the POS can be reviewed by a nurse for relatedness to the injury conditions in the claim. If appropriate, the nurse makes contact with the treating physician to discuss the medication treatment plan. For any question of medical necessity, a physician advisor reviews the requested medications and provides recommendations.

A physician from our comprehensive network of qualified specialists can perform a peer review of ongoing medications to address medical appropriateness and relatedness to the work injury.

Our experience shows that the best results for our clients are obtained through working cooperatively with treating physicians. Upon referral, we notify the treating physician of the drug utilization review and request additional information regarding the medication treatment plan to be considered by our reviewing physician.

Furthermore, our physician reviewer may choose to discuss the medications with the treating physician. Upon completion of the review, written recommendations are provided to the self-insured employer and/or claim adjuster.