Services

- Performed by the PC's in their offices
- A complex file can be summarized by an RN who poses specific questions

Nurse consultant can assist in determining what type of medical evaluation is indicated.

- For complex cases with extensive records, multiple conditions
- An RN does a chronological review of the file; PC opinion is optional
- Discussion and conclusions provide rationale and points of strength

A record review has three sections. Section one is a brief summary of the medical records reviewed. Section two outlines, with reference to specific medical records, all issues that would appear to be impacting the case. Section three is the conclusion.

- Performed by consulting physician
- Causation and if treatment is related to accident can be addressed

- Up-to-date medical database research into conditions or techniques
- Research data can be submitted to a PC for medical opinions
- Research data can be applied to a case or stand alone

A literature review is a record review with references to research to substantiate the recommendations and conclusions.

- RN's bring laptop computers to your office and review files
- PC opinions can be obtained over the telephone to the RN
- Treating practitioners may be telephoned to discuss claim issues
- Immediate answers, low cost, clear documentation for your file

Advantages include not having to make massive copies, getting answers quickly (usually the same day), and reduced costs.

- RN's telephone or meet with treating physician and /or claimant
- Issues addressed may include treatment, return to work, compensibility

Case management involves effective nurse intervention to direct a claim towards resolution. Case management is a coordination of care between the employer (if applicable), the providers and the claiment. It is specific with timely goals (not case monitoring). Results are oriented to include benchmarks and critical pathways.

- RN examination of the billing and the treatment notes
- Recommendations for allowance/disallowance of charges submitted
- Can be used in conjunction with the Usual Customary review

An RN Consultant will examine the treatment notes and the CPT codes billed in order to determine if the billed modalities are substantiated by the documentation, and if the treatment rendered follows specific industry-standard guidelines. A brief report summarizing the injuries and treatments rendered will be completed. The report will include recommendations of payments to allow or disallow, additional records to request for review, or if referral for a physician file review or IME is recommended.

- Review of the billings for appropriate amount charged for each CPT code

The billed CPT codes will be reviewed and the charges will be subjected to the "usual and customary" amounts for the zip code region in which the services were rendered. The RVS, or Relative Value Survey, being used was compiled by Medicode, and the 75th percentile is used.