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5:19:14 AM CDT
Wednesday, April 16, 2014

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Managed Care

What is managed care?

Managed care is sometimes described as cost containment. A common misconception is that managed care restricts access to providers and reduces care. Managed care is geared toward ensuring quality, appropriate medical care that is cost efficient. Our four components of managed care are 1) the designated medical provider; 2) utilization review; 3) bill audit; and 4) fee schedules.

- Component #1: The Designated Medical Provider (DMP):

Employers can select a designated medical provider (DMP) to provide medical services to their employees. By being a DMP, you will gain a solid base of knowledge about the employer's business, which will assist you in making decisions on return-to-work issues concerning injured workers.

- Component #2: Utilization Review:

Utilization review is the process of evaluating proposed medical services for efficiency, appropriateness, and medical necessity. Utilization reviewers compare proposed treatment to guidelines and criteria developed by a national panel of physician specialists, which is reviewed and updated annually as necessary. Medical utilization review at the first level of review is performed by registered nurses. If proposed treatment does not meet the guidelines, the nurse refers the case to a physician advisor for further review and consultation with the treating provider.

Utilization review consists of the following elements:

  • Preservice review is the evaluation (by WSI or a managed care vendor) of a proposed medical service for medical necessity, appropriateness, and efficiency prior to the service being performed.

  • Concurrent review is the monitoring (by WSI or a managed care vendor) of the injured worker’s condition, treatments, or procedures for medical necessity and appropriateness, throughout the period of time in which medical services are being provided. For inpatient hospital stays, concurrent review is required when the length of stay exceeds 14 days.

  • Retrospective review is a review (by WSI or a managed care vendor) of a medical service for medical necessity, appropriateness, and efficiency after treatment has occurred. Retrospective review is limited to those situations when the provider can show that the injured worker did not inform the provider, and the provider did not, in fact, know that the condition was, or likely would be, covered under workers’ compensation.

  • Appeal or second-level review is another review of a service that was initially found to be not medically necessary. Appeals must be requested within 30 days of the original review determination.

To expedite the review, please use the following form:
Utilization Review Request (UR-C)

For services that require utilization review through WSI's Utilization Review Department, view our Utilization Review Guide. If you have questions regarding utilization review, call WSI at (701) 328-5990 or 1-888-777-5871.

Chiropractic care after the first 12 treatments or first 90 days, whichever comes first, requires pre-service review through a managed care vendor. Chiropractic providers are to contact Orthopedic Chiropractic Consultants at 1-877-211-1906 with any questions. The Chiropractic Progress/Final Report form (C25) is to be used as the final report on the injury.

- Component #3: Bill Audit:

Substantial savings can be realized with the use of bill audit services that identify the invalid medical charges of hospitals, physicians, and other medical providers. Workers' compensation is not required to pay invalid charges. Types of invalid charges:

  • Excessive - A charges that exceeds statutory-prescribed fee schedules or customary fees.
  • Upcoded - A charge for a procedure that has been misrepresented as a more expensive procedure.
  • Unbundled - One procedure or a series of procedures that have been divided up for billing purposes into smaller units so the total cost of the units exceeds what should have been charged.
  • Overutilization - A charge for a service that has been rendered more times than necessary.
  • Noncompensable - A charge for a service that are not covered under workers' compensation (such as a non-occupational injury being charged as a workers compensation injury).

Please note that all bills must be submitted to WSI within one year of the date of service or within one year of the date WSI accepts liability for the work injury or condition.

- Component #4: Fee Schedules:

A fee schedule is a list that establishes the recommended maximum level of reimbursement for medical services. A fee schedule usually has two parts: a relative value scale and a monetary conversion factor. Some fee schedules may list actual dollar amounts. Many workers' compensation fee schedules also establish guidelines for the payment of services. The guidelines may include limitations on the number of units of service, restrictions on the frequency of service, requirements for treatment plans, and requirements for referrals.

To view the fee schedules, you must first accept this disclaimer statement. You can also request a hard copy of our fee schedules by completing the Fee Schedule Request form.

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