In Contra Costa County Schools Insurance Group’s ongoing efforts to manage rising workers’ compensation costs we have several tools available to our claims staff. Three of the largest cost containment components are as follows:
CCCSIG utilizes a telephonic claims reporting tool through Company Nurse. This program (staffed by Registered Occupational Nurses utilizing medical triage protocols) benefits the employee and will reduce or in some cases eliminate, the paperwork at the site and district levels. This program assists the employee, CCCSIG and the district in returning the employee to work, on the day of injury, when medically possible.
Pharmacy Benefit Management Program
CCCSIG teamed up with myMatrixx, a pharmacy benefit management network, to provide a prescription drug program for work-related injuries. This program is available for all compensable work-related injuries with access to over 50,000 pharmacies, mail order services and a registered pharmacist available 24 hours a day. Injured workers are provided a Prescription Services ID so they do not have to incur out-of-pocket expense. For a complete list of participating pharmacies, call the toll free number 1 (877) 804-4900 or access myMatrixx’s extensive network at www.mymatrixx.com.
Early Return to Work Program
CCCSIG has an established, proactive Early Return to Work Program that is designed to assist employees while decreasing costs of work related injuries by immediately providing a temporary work assignment (TWA) to the injured worker with district cooperation. The TWA allows the employee to remain in the workforce and aids in their recovery.
Nurse Case Manager
The CCCSIG Nurse Case Manager assists our claims department and districts with on site case management of both general and catastrophic claims. The nurse consults with physicians and assists in reviewing treatment plans and helps facilitate optimal and efficient recovery for the injured employee.
Bill Review Service
CCCSIG has its own bill review team that reviews all medical and pharmacy bills to ensure that all charges are in accordance with the California official medical fee schedule.
American College of Occupational and Environmental Medicine (ACOEM)
The American College of Occupational and Environmental Medicine (ACOEM) Practice Guidelines Committee recently developed and published the second edition of Occupational Medicine Practice Guidelines. These guidelines are also frequently referred to as “ACOEM Guidelines” throughout much of the workers’ compensation industry.
As a result of legislative efforts to contain rising medical costs in workers’ compensation and provide improved medical care for injured workers the ACOEM guidelines became effective on March 22, 2004. As of that date the ACOEM guidelines became presumptively correct for all medical treatment of occupational injuries. The ACOEM guidelines consider the frequency, duration, intensity and appropriateness of all modalities and procedures that are most commonly used in the treatment of injured workers.
Because ACOEM guidelines are now presumptively correct, this means that every physician must now treat his or her patients in accordance with ACOEM. Physicians who treat outside of the established evidence-based ACOEM guidelines are subject to having their treatment plans sent through a Utilization Review process to determine if their treatment is reasonable and necessary. It is up to the physician to explain why his or her requested mode of treatment, although not in accordance with the ACOEM guidelines, is the best mode of treatment for the injured employee.
According to new legislation, every employer is required to establish a utilization review process in compliance with LC 4610. Utilization review is the process used to prospectively, retrospectively, or concurrently review, approve, modify, delay or deny medial treatment based in whole or in part on medical necessity to cure and relieve treatment recommendations by physicians.
The utilization review process can be performed directly by the insurer or an entity which the insurer or employer contracts for these services.
- Concurrent Review: Utilization review conducted during an inpatient stay.
- Prospective Review: Utilization review conducted prior to the delivery of medical services.
- Retrospective Review: Utilization review conducted after medical health services have been provided.
Once a physician’s treatment request has been sent through the Utilization Review process the employee can expect one of the following things to occur:
- Approve: Utilization review determines that the treatment request is reasonable and necessary and will recommend authorization of the medical treatment in accordance with ACOEM guidelines.
- Modify: Utilization review determines that the treatment request should be modified and will make recommendations for the modified treatment as it relates to ACOEM guidelines. For example the physician may have requested ten physical therapy visits and utilization review may modify the request by only recommending five visits in accordance with ACOEM guidelines.
- Delay: Utilization review determines that the treatment request is something that may be beneficial only if other treatment modalities are used first and fail to cure or relieve the effects of the injury. For example, the physician may have requested a particular surgery but ACOEM guidelines first recommend that injections and physical therapy be provided as the initial treatment modalities. If proven ineffective then surgery is recommended.
- Deny: Utilization review determines that the treatment request is unreasonable and not necessary to cure or relieve symptoms of the injured worker in accordance with the ACOEM guidelines.
In each of the above scenarios, the injured worker and physician will be notified in writing of the utilization review outcome except when the treatment is approved. Instructions for appealing any utilization review decision are provided to the physician in writing at which point he or she can begin the appeal process.