Cost Containment

Introduction

You are not a cookie-cutter business, and neither are we. We recognize that every client is different, with a unique set of requirements. Our senior management team alone has more than 52 years of experience in workers' compensation. This enables us to design a flexible solution that accommodates your special needs.

We take an employer-centric approach to workers' compensation with cost containment services that protect the workforce with timely, cost effective, and appropriate medical care. This provides all stakeholders - employers, TPAs or insurance carriers - with the ability to improve the return-to-work cycle.

At the center of our services is the latest technology that allows the nurse, claims adjuster and employer access to real time information to ensure the best possible outcome for all.

• Customer service emphasis, with flexibility in the design of the cost containment services
• Fully integrated cost containment programs that "talk" to each other, minimizing errors and omissions
• True partnership with clients to identify further cost savings, backed by a cohesive plan of action
• An unequaled quality assurance program that constantly reviews both qualitative and quantitative best practices, with individual accountability for all RiskSolutions, Inc. staff
• Client-focused staff with intimate knowledge of your needs and special protocols

Since the advent of utilization review, through either HCOs (Health Care Organizations) in 1992 or SB899 in 2004, California has been a leader in showing the value of a proactive approach to the management of healthcare through utilization management of medical care. The key is to review the proposed treatment plan for:

• Medical necessity
• Compliance to state mandated best practices such as ACOEM (American College of Environmental Medicine), or ODGs (Official Disability Guidelines - Work Loss Data Institute) and MDA (Medical Disability Advisor)
• Reduction in over utilization of physical therapy, chiropractic care and narcotic medications

Timeliness is essential. Adjusters are mandated by law to protect workers from delayed treatment. With the potential for penalties, it is even more essential to maintain the timeframes. Our deadline driven workflow protocol gives RiskSolutions, Inc. 100% adherence to statutory timeframes. This reduces your cost and maintains compliance.

RiskSolutions, Inc. Utilization Review Program includes:

• Prospective review
• Concurrent review
• Retrospective review
• Peer review

Our medical bill review process provides an automated system for reimbursement evaluation. Our system reviews for the following:

• Coding review and rebundling
• Usual and customary review
• Hospital bill review
• Pharmacy review
• Analysis with the Medical Fee Schedule of the appropriate state
• Repricing

We are proud to concentrate on quality through our decision based software. We have devoted staff to our Quality Assurance Department to ensure that any of our products is at the highest of quality and error free. We can provide same day reviews to ensure timeliness to avoid costly penalties.

RiskSolutions, Inc. provides workers' compensation nurses with extensive occupational health backgrounds. The nurse case manager is a key part of facilitating integrated healthcare. The nurse case manager facilitates getting the patient with the appropriate healthcare provider, treatment plan and return to work to ensure the optimum outcome for all stakeholders.

Our Case Management Services include:

• First Notice of Loss - Employers' First Report of Injury data entry and filing with the appropriate carrier
• Day One Medical Triage Services which puts a nurse monitoring injuries telephonically for the first 60 days for a flat rate
• Telephonic medical coordination of workers' compensation injuries
• Field medical coordination of workers' compensation injuries where appropriate
• Onsite medical coordination of workers' compensation injuries where appropriate
• Integrated Disability Management
• Online case notes