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The first days of a claim are critical
in that the decisions made can greatly effect the course
and outcome. Early referral will reveal claims needing
Utilization Management to achieve Early Intervention.
The process of making well informed claims decisions
and implementing them can be greatly enhanced through
early assessment of and intervention (if necessary)
in the medical care provided. Potential problems or
barriers can be mitigated early and a positive employer/employee
relationship can be fostered. The use of professionally
developed and defensible treatment criteria (ACOEM and
Milliman Care Guidelines) allows us to optimize delivery
of reasonable and necessary care.
To quickly evaluate the ill or injured
employees present status. To facilitate use of the most
appropriate treating physician and ensure the effectiveness
of the medical providers treatment plan. To extend the
'window of control' beyond the 30 days given the employer.
To clearly identify existing and potential barriers
to progress and provide specific recommendations for
intervention. To ensure the needs of the employee are
met to reduce the incidence of litigation. To apply
medical cost containment and utilization management
strategies. To develop a comprehensive medical treatment
plan with the physician, patient, claims staff, and
employer to positively impact the length, course, cost
and outcome of the care provided. To advocate for wellness
and return to productivity and not allow unproductive
enabling of a disability lifestyle. To get the employee
to permanent and stationary medical status with the
highest level of functioning possible and released to
return to work.
To provide the employer and claims staff
valuable information and empower them to make timely
and well informed decisions. To work closely with the
employer to impart a "We Care" attitude to
the employee. To maintain a productive employee / employer
relationship to maximize any potential to return to
modified, light or regular duty work as soon as possible.
To work closely with the treating physician and ill/injured
employee to achieve timely and appropriate treatment
planning, cost effective implementation and follow through.
To maximize medical improvement to permanent and stationary
status as soon as possible. To create a "Sentinel
Effect" wherein the physician and employee know
that a qualified medical professional is personally
overseeing and involved with their recovery and return
to work.
Through Medical Case / Utilization Management
we will positively effect the overall medical unit and
utilization costs, the indemnity and permanent disability
costs and the personal and industrial costs of illness
and injury in the workplace. You will achieve a higher
return to work rate and a more expeditious attainment
of permanent and stationary status (medically stationary
in OR).
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