HCRG provides a fully comprehensive Medical Management and Medical Bill review service for liability insurance claims. We partner with our clients and manage the medical cost and severity of their liabilities. Our experienced and credentialed medical risk management, clinical and bill review team works together to ensure that the medical treatment services and bills are cost effective, necessary and appropriate for the specific liability. We provide evidence based and objective evaluation of medical records and medical bills and make recommendations for medical service payment, reserve setting, medical management, and settlement of claims.
• Medical Chart Review
• Medical Bill Review
• Medical Payment Negotiation
• Medical Legal Review
• Reserve Medical Needs Assessment
• Medical Management Services
• Life Care Planning
OUR PROGRAM GOALS:
• Decreasing the cost and the severity of your liability.
• Provide information to adjusters for the cost effective administration of cases.
• Provide supportive expert medical management and bill review services.
• Provide resources and access to the most current evidence based information about medical treatment and healthcare rehabilitative techniques.
• Provide medical-legal support where needed and as required.
Medical Chart Review
Our team of experienced and specialized professionals evaluate and analyze the medical records and provide an evidence driven, clinically reasoned and carefully documented evaluation that outlines medical necessity and reasonableness of services rendered. Our medical chart review process is designed specifically for liability payers. We follow a structured methodology designed to identify alignment of medical services to actual injury. When appropriate we evaluate the effect of co-morbidity of the injury trajectory and determine reasonable related medical services.
The following are analyzed:
• Correct diagnosis
• Alignment of diagnosis with injury
• Documentation of clinical encounter
• Medical necessity documentation
• Utilization of procedures, medications and DME appropriateness
• Management of care
• Management of co-morbidity
We provide comprehensive reports for our clients. Our reports contain information necessary to make decisions. When necessary we consult face to face with the claims management team to discuss recommendations based on medical chart review, and assist on making decisions on the continued care of the claimant.
MEDICAL BILL REVIEW
High cost is usually at stake with the delivery of medical services. We utilize our highly credentialed team, proprietary methodology and software to ensure that medical bills are reviewed appropriately with the utmost accuracy. Our team of certified coders, bill reviewers and clinical professionals conduct a detailed review of each bill.
We focus on the following:
• Correct diagnosis
• Relationship of bill to compensable injury
• Accuracy of medical billed services
• Line item billing
• Duplicate line billing
• Technical coding, CPT, ICD-9, HCPCS, J-codes, E-codes, etc.
• Discrepancies between charges and services rendered
• Negotiation possibilities
Our Medical Bill Review is accurate. We provide an explanation of benefits that are utilized by the claims team for use in the payment of bills. At HCRG we stand by our bill review.
MEDICAL PAYMENT NEGOTIATION
In cases of large and complex medical bills, there might be a place for further cost containment negotiation after conducting a full bill review. HCRG has a special program in place that is designed to negotiate with the payer for further discount. When the medical bill fits the criteria and upon approval from the client, HCRG aggressively attempts to reduce the bill amount beyond bill review recommendation.
MEDICAL LEGAL REVIEW
HCRG’s experienced team of clinical professionals is equipped to assist the legal team with issues related to medical legal situations. We provide the following services to assist the legal team:
• Medical file review and analysis
• Chronological review of medical records
• Medical services and organization utilization
• Evidence based research and analysis
• Medical cost estimate for long term care
• Life care planning
• Expert testimony
RESERVE MEDICAL NEEDS ASSESSMENT
Reserves must be properly implemented to be successful in claims management. It is sometimes challenging for claims adjusters to ensure that claims are being adequately reserved. A medical needs assessment from time to time is required to provide adequate data for decision making. We provide a fully comprehensive medical needs assessment service. This service consists of conducting a chart review and make recommendations on the expected trajectory of the claim. An estimated cost projection for medical services is made and reported to the adjusters. The estimate of medical cost includes physician visits, specialty visits, medication, DME, expected complication. We provide the adjuster with the essential date required to set the reserve on the claim. We work alongside the claim adjuster.
MEDICAL MANAGEMENT SERVICES
Medical care is expensive and must be managed effectively. The liability claim management team must ensure that medical care obtained by claimant is appropriate and medically necessary. We provide an evidence based utilization management program to assist the liability claims management team to effectively manage medical care. Our clinical team composed of administrative staff, registered nurses and physicians objectively evaluates each medical service requested and review whether they are medically necessary based on clinical and evidence based criteria. We provide a report to the claims management team. When necessary our nurses or medical doctors may initiate peer to peer discussions with the physician requesting service to discuss medical necessity and plan how to proceed further. This service is essential in managing medical expense.
Managing timely care delivery, rehabilitation and return to work is essential to manage the claims and expenses. Managing barriers to recovery is essential in moving a claim forward towards timely return to work. HCRG provides Telephonic Field and Catastrophic Case Management Service. We coordinate treatment plans, clarify medical diagnoses, identify pre-existing conditions, and design and implement treatment plans in collaboration with the claims managers and the injured individual. When appropriate, we negotiate prices for treatment, equipment and services to contain cost. Our team also evaluates treatment plans and proposes alternatives.
LIFE CARE PLANNING | LONG TERM MEDICAL COST PROJECTIONS
HCRG provides Life Care Planning and Long Term Medical Cost Projections. Life Care Planning and Long Term Medical Cost Projection may become required in specific cases to plan the settlement and/or the long term planning of the case. Our team of credentialed and certified staff conduct a detailed chart review and based on the findings formulate an evidence based healthcare requirement trajectory over the expected lifetime of the individual. Cost allocation is projected. A detailed report and consultation is provided to the claims management team.
The program provides:
1. Identification of medical care requirements
2. Identification of required medical equipment, pharmacy services and therapy
3. Projected fulltime cost of a lifetime medical care
6571 Altura Blvd.,
Buena Park, CA 90620
“HCRG’s multi-faceted approach to General Liability services is unparalleled in the industry.”