Utilization Review Program

Reasonable Medical Treatment and Costs

Given that utilization of medical care in a workers’ compensation claim is the crux of the entire case, controlling it is critical, especially since medical costs have more than doubled over the past 10 years.

Prior to and during the time that care is rendered, Allied Managed Care’s concurrent, and prospective utilization review services ensure that medical care is screened and monitored for necessity, suitable frequency, and appropriate duration. Our retrospective utilization review service ensures that payments made for care already administered are made in accordance with all rules, regulations, and fee schedules.

Features

• Assist claims examiners in determining whether medical providers’ treatment requests are reasonable according to a comprehensive database of medically based criteria

• An appointed Medical Director oversees the Peer Review services included in the Utilization Review program.

• Qualified, certified experts monitor frequency, duration, and appropriateness of medical services

• Pre-certification screening of hospital, surgical, and diagnostic requests evaluated for appropriateness

• Any required written Utilization Review plan will be submitted to State regulatory agencies on the client's behalf

• Utilization review of ongoing requests for any and all medical services in open claims

• Payments for previously administered treatment made in accordance with all state rules, regulations, and fee schedules

Benefits

• Protect patients and physicians from inappropriate denial of treatment

• Control medical costs by ensuring that prescribed medical treatment is reasonable and necessary in duration and frequency based on the respective diagnosis

• Hard dollar savings on review of retrospective medical care

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80 South Lake Avenue, Suite 500 ~ Pasadena, CA 91101 ~  (800) 431-6336 ~ (626) 441-3999 ~ Fax (626) 441-3799