Comprehensive Services

Picture Total Managed Care, Inc. views its mission as achieving the expeditious restoration of health and productivity to those who have lost them by illness or injury, and to minimize disability while maximizing ability retention. Our goal is to efficiently and effectively manage the medical recovery and return to work process, thereby increasing the return on medical expenditures, and lowering medical and indemnity costs.

Total Managed Care, Inc. has developed a comprehensive array of services to facilitate this goal including:

  • Medical Utilization Review
  • Telephonic and Field Case Management
  • Return To Work Programs
  • Medical Bill Review and Auditing
  • Medical Provider Network Development

Total Managed Care's Utilization Review Program

Picture Medical utilization review activities should be initiated when a question regarding medical necessity of any proposed treatment or service arises from any written request for service. It may also be initiated if an injured worker questions the necessity or validity of treatment recommendations.

Total managed Care's Utilization Management Program meets the standards set forth in the Workers' Compensation Labor Code for approval, modification, delaying, or denial based in whole or in part on medical necessity.

All certifications are performed by licensed RN's. All pre-certifications or reviews are criteria based, and subject to additional information from the provider. Total Managed Care's protocols for Utilization shall ensure that decisions are made on scientifically based evidence, and if they are not appropriate, will be sent for a physician peer review.

Utilization Management includes:

  • Physician Peer Review.
  • Hospitalization and Surgery.
  • Diagnostic Imaging.
  • Epidural Injections.
  • Acupuncture
  • Outpatient Surgery.
  • Physical Therapy.
  • Chiropractic Care.
  • Pharmaceutical Treatment.
  • Durable Medical Equipment.
  • Catastrophic Claims.

Telephonic and Field Case Management Services

Picture Total Managed Care's Case Management professionals are responsible for the overall administration of medical care for injured workers. Sometimes severe injuries, complex medical treatment plans, or cases where treatment plans are not proceeding appropriately require the services of Nurse Case Managers to provide either telephonic management of medical services, or on-site management of more serious cases.

Total Managed Care applies its medical expertise to a variety of settings - Workers' Compensation, liability, group health, disability, or long term care - to manage costs, and minimize exposure. Some of the areas this expertise is applied to include:

  • Early intervention and telephonic case management with medical and disability management.
  • On-site medical and vocational case management.
  • PPO channeling and re-pricing.
  • Medical bill auditing.
  • Pre-certification and concurrent reviews on treatment, testing, and hospitalization.
  • Short term and long term disability cost management resources for employeers and insurance carriers.
  • Absenteeism Management.
  • Return to work coordination.

Total managed care gives employers and insurers the necessary tools to control medical and disability costs and return employees to work as quickly and safely as possible.

Return To Work Programs

The Bureau of Labor Statistics reports that if an employee is off work for six months due to occupational injury or illness, there is only a 50 percent chance of that employee returning to work. If an employee is off work for one year, there is less than a 25 percent chance of that employee returning to work.

Total managed Care is committed to assisting employers in promoting a successful return to work by assisting in the development and implementation of programs to ensure that the employee is returned to a safe and healthy work environment. Some of the components of a successful return to work program can be:

  • Development of return to work procedures.
  • Assistance in developing modified or alternative work by identifying essential job functions.
  • Furnishing the provider with a job description.
  • Communicating with, and training of the employee.

Some of the benefits of a successful return to work program include: Picture

  • Reduces workers' compensation claim costs.
  • Returns the injured employee to work as soon as medically possible.
  • Promotes positive employee morale in the workplace.
  • Utilizes a recovery period to maintain productivity.
  • Discourages malingering.
  • Lowers medical costs.
  • Promotes communication rather than litigation.
  • Promotes cross training.
  • Preserves a skilled and stable work place.

Medical Bill Review and Auditing

All medical bills submitted to Total Managed Care for payment will be analyzed and re-priced by our Bill Review department. We utilize Comp IQ, a state of the art computer program which is designed to correctly re-price bills to applicable State Fee Schedules, and will factor in Provider Network Discounts. All bills are reviewed for unbundled charges, and comparisons of treatment procedures to any utilization review performed for requested services are made to ensure accuracy. All bills are processed within our office in less than three days. Picture

All hospital bills in excess of $5,000.00 which are not subject to State Fee Schedules or PPO contracts will be audited to determine appropriate pricing on a line by line basis. All bills are negotiated if no obvious auditing defaults are discovered.

Medical Provider Network Development

Picture In conjunction with Utilization Review Services, this service can save thousands of disability dollars for the employer.

Unlike a typical doctor/patient relationship, the physician's role with injured employees is not limited to diagnosis and treatment. It may be the physician who is the first to raise the possibility that the employee's condition is work related.

Many physicians in routine PPO partmerships have not been specifically trained to recognize occupational injury/illness in early stages, or how and when to set the tone for the injured worker to understand the treatment plan, expected duration of treatment, or when and how to return the injured worker to modified or full functionality.

A unique benefit in developing a smaller, well trained physician network lies in the focus on functionality and disability management as the primary goal. This goal necessitates working as part of a team that includes the employer, claims adjuster, healthcare provider, nurse case manager, and most importantly the injured worker.

Some of the benefits provided by a smaller, well controlled provider network are:

  • Earlier determination of medical causation.
  • Early diagnosis and treatment.
  • Setting work restrictions consistently and earlier release for transition work whenever possible.
  • Better communication of the claimant's functional status to the employer and claims administrator.
  • Earlier determination of when the claimant reaches P&S.
  • Determining medical eligibility for Vocational Rehabilitation services at the earliest possible moment.
  • Managing and coordination of the claimant's care from First Report of Injury.
  • Timely submission of accurate reports.
  • Referral to consulting physicians (also in the Network) earlier, thereby preventing the claimant from opting out of the system.
  • Earlier decisions regarding diagnostic testing through established work flow with case managers and protocols for standards of care.

Total managed Care will build and develop a physician network for your organization that meets the standards of care which your injured worker deserves, while meeting the standards you as the employer deserve.

bottom corner