Medical Bill Audits
Bill audits ensure charges are related to allowed conditions and within medical necessity guidelines.

• A nurse reviews bills to reflect maximum savings while still observing any jurisdictional requirements that may exist.
• Bills are reviewed line-by-line to determine the relationship of billed amounts to documented procedures and relevance to the allowed claim.
• We ensure that the employer only pays for services medically related to the claim and allowed conditions.
• The cost for hospital bill audits is only a percentage of the realized savings; therefore the employer reaps the majority of cost savings.
• Our nurses can defend audit recommendations if questioned by a provider.

Physician File Reviews
Appropriate physician specialty completes a paper review of file to address treatment needs.

• Questions and issues written and reviewed by a Registered Nurse.
• Evaluation by physician to determine if current treatment and retrospective treatment is appropriate and related.
• Written report completed and returned promptly.

Utilization Management
Nurse-driven review to ensure appropriateness and cost-effectiveness of treatment.

By managing treatment—and negotiating the treatment, if necessary—we ensure that the injured employee receives only appropriate necessary care. Employers benefit when costly, unessential medical procedures that could delay recovery are reviewed. National treatment guidelines and appropriateness criteria support the review process.

Disability and FMLA Absence Management Services
Saving money through total absence management.

Top Five Objectives of Short-Term Disability and Integrated Benefits Management:

1. Cost Savings
2. Productivity/Return to Work
3. Employee Health & Safety
4. Employer Process Simplification
5. Employee Satisfaction

Positive return-to-work outcomes are essential for the management of employee absences due to disability and FMLA. Customization is the difference. We work with each customer individually, developing personalized programs that meet your unique needs.

Programs can include:

• Early reporting of initial absences through toll-free or Internet reporting options.
• Immediate nurse triage to establish medical treatment and return-to-work plans.
• Securing current physical abilities/restrictions from treating providers.
• Coordinating transitional return to work with the employer.
• Facilitating progression to full-duty return to work with case resolution.
• Communicating effectively with all payer and documentation sources.
• Providing reports and data.

The Basics of Life Care Planning & Medicare Set Asides Important service option in defense of Permanent Total Disability applications.

What is a Life Care Plan?

• A Life Care Plan is essentially a long-term plan of care that addresses the needs of a person who has sustained a catastrophic injury or illness.
• The goal of a Life Care Plan is to identify services and equipment as well as the associated costs that a person will incur in their life as related to their injury.
• The Life Care Plan is able to serve not only as a case management tool, but also as a tool for litigation to identify the needs and associated costs of those with a catastrophic injury or illness.

Who Needs a Life Care Plan?

• Any person who has sustained a catastrophic injury or a catastrophic illness and needs a guideline for the medical intervention, long-term care, equipment needs, replacement schedule and other associated costs.
• All parties involved including the individual, involved loved ones, treating professionals and legal counsel will benefit from information included within a formal Life Care Plan.

Who Writes Life Care Plans?

Who Utilizes a Life Care Planner?

• Life Care Planners are utilized by attorneys representing those with injuries or illness, insurance firms, trust officers, workers’ compensation agencies, as well as family members of the affected individuals.

What is a Medicare Set Aside?

• A Medicare Set Aside is a fund created in a settlement as a result of a workers’ compensation and/or a liability claim. The agreement is used to allocate a portion of the settlement for future medical expenses and the amount of the set aside is determined on a case-by-case basis.

When should an evaluation for a Medicare Set Aside be completed?

• If a person is a Medicare beneficiary at the time of settlement, regardless of the amount of the settlement.
• If a person is not a Medicare beneficiary at the time of settlement and the settlement is over $250,000.00 and a “reasonable expectation” exists of Medicare enrollment within 30 months of settlement, a Medical Set Aside is required. The concept of “reasonable expectation” includes, but is not limited to, the following factors:
  • Receiving Social Security benefits at the time of settlement.
  • Has been denied SSDI but is considering appealing or reapplying.
  • If the injured worker is 62 years and six months old, the injured worker will be Medicare-eligible within 30 months.

A CareWorks USA nurse can facilitate the determination of the set-aside amount. Once you have identified a file that meets the criteria for a Medicare Set Aside, please contact your CareWorks USA Account Manager.