PRE AUTHORIZATION 

Southwest Medical Examination Services Pre-Authorization department utilizes established medical criteria to determine appropriateness of care and causal-relationship of proposed treatment before it occurs.  For complicated cases, or cases that fall outside the medical criteria, physician involvement may be indicated. 

SME has the ability to custom-tailor the current system to meet the Pre Authorization needs of our respective clients.  Through the utilization of SME’s staff physician advisors, our clients will not only become more proficient due to timeliness, but will also improve the integrity of the responses.

SME currently utilizes fifteen Board Certified Physician Advisors to rule on complicated and disputed cases.  SME has developed and maintained relationships with several of these physicians since the inception of the company in 1992.  Many of the Physician Advisors are at an SME location several days a week.  This allows SME to meet and exceed time constraints and also allows the Pre Authorization nurse to discuss complicated issues with the physician.

Pre-Authorization cases may be referred to the Southwest Medical Pre-Authorization department via the dedicated 800 phone or fax line.  Once the case is received, the nurse will gather all pertinent medical records needed to make a determination on the case.  Recommendations will be made and faxed to the appropriate party within the allotted time. 

Pre-Authorization should be considered for the following types of care:

*          Chiropractic                                                     *          Psychiatric

*          Outpatient Surgery                                            *          Biofeedback

*          Pain Management                                             *          Chemical Dependency

*          Dental                                                              *          Work Hardening

*          Physical Therapy                                              *          Durable Medical Equipment

*          Nursing                                                            *          Video Fluoroscopy

*          Diagnostic Testing                                             *          MRI

*          Non-Emergency Hospitalizations  

Utilization of Southwest Medical Examination Services Pre-Authorization service on a consistent basis will prove to be advantageous in reducing the number of unnecessary treatments before they occur.

The goals of Pre-Authorization are as follows:

*          To decrease medical expenditures

*          To assure appropriate time parameters are assigned Physical and Chiropractic Therapy

*          To assure treatment is appropriate and causally related to the original injury

*          To assure discharge planning has been accomplished

*          To identify cases that could benefit from field case management or peer review

MEDICAL BILL REVIEW 

Southwest Medical Examination Services will provide our clients with a custom-tailored bill auditing program that will significantly reduce the costs associated with workers’ compensation claims.  Our services have proven to show savings from to 28 to 42 percent respectively.

Southwest Medical Examination Services bill auditing program is administered by thoroughly trained staff.  All bill auditing functions will be performed in our Dallas, Texas headquarters.  The turn-around time for our service is extremely competitive at 3-7 working days.

The bill auditing process:

*          Bills packaged and sent to SME office

*          Bills batched and reviewed for type and legibility

*          Bills entered into system

*          Software reductions applied

*          PPO discounts applied

*          Bill reductions totaled

*          Explanation of Review (EOR) printed and attached to bill

*          Transmittal of results to the state (if necessary)

*          Bills and EOR’s sent returned to client

Duplicates/Reconsiderations:

*          Duplicates identified and sent back to customer and marked as such

*          Reconsiderations are processed with the extra documentation from provider (See Process Above)

*          SME and software provider will handle all dispute resolutions and reconsideration questions

Functions of SME Medical Bill Auditing Program Includes: 

*          Reduction of workers’ compensation medical bills through comprehensive software package

*          Trained audit specialists to reduce service levels that are not warranted

*          Ensuring all procedures billed were completed

*          Software that has the ability to recognize duplicate bills and provider unbundling

*          Ability to transmit to the TWCC and other state agencies

*          Variety of EOR formats available

*          May raise red flag to watch providers that frequently over-utilize medical services

*          Ensuring appropriate treatment

*          System linked directly with Pre Authorization software to recognize denials on claims that have been submitted for Pre Authorization

PPO Network Benefits:

Southwest Medical Examination Services has the ability to access a national PPO network that will ensure savings beyond that of the audit.

*          The Focus network is one of the largest PPO networks of its kind

*          The Focus network specializes in workers’ compensation

*          Requires providers to maintain minimum credentials

*          Providers are required to maintain a minimum on their liability insurance

INDEPENDENT MEDICAL EXAMINATION

Southwest Medical Examination Services has developed a unique service in regard to the Independent Medical Examination (IME).  We have produced a network of over 150 physicians throughout the states of Texas and California to provide an independent and reliable second opinion. 

The Independent Medical Exam is a cost-reduction tool for workers’ compensation claims.  It is a physical exam in addition to an assessment of medical records that enhances, clarifies and interprets complex issues in a claim.  The IME provides insight from Board Certified Physicians with injury and industry specific knowledge that enables us to address all specific issues in a claim through a comprehensive physical evaluation and report.

SME provides each account with a dedicated marketing representative.  The representative is responsible for copying all pertinent medical records, discussing issues with the adjuster, making recommendations for the utilization of the appropriate physician and to maintain a rapport with the clientele.

An Independent Medical Exam may be used to address the following:

*          Maximum Medical Improvement

*          Impairment Rating

*          Causation of the injury

*          Extent of the injury

*          Appropriateness of medical treatment

*          Establish a comprehensive future treatment plan

*          The ability to return to work and current work restrictions

*          If treatment rendered was due to a pre-existing condition

*          Recommend and or perform additional diagnostic tests which may provide additional insight to assist in clarifying the above issues         

PEER REVIEW

The Peer Review is a retrospective review of pertinent medical records that may be used as a cost-reduction tool.  The Peer Review is used to address many of the same issues as the Independent Medical exam, but is only a review of medical records rather than a physical evaluation of the injured employee.

Southwest Medical Examination Services employs a registered nurse that will organize and summarize all pertinent medical records received from our clients.  The nurse liaison will at this point determine which physician will be appropriate to evaluate the medical issues.  All issues presented by our clients, which are addressed by the reviewing physician will be posed in appropriate medical terminology.  The physician will then dictate their response on the proposed issues to Southwest Medicals’ transcription department.  Once the report has been transcribed, it will go back to the nurse for review.  Any issues not properly addressed will be returned to the reviewing physician.  When the report has been finalized, copies are forwarded to all appropriate parties.  The standard turn-around time for this service is 7-10 working days.

The Peer Review may be used to address the following:

*          Whether treatment rendered was medically necessary

*          If current condition may be related to a pre-existing condition

*          Medical necessity of a hospital admission, surgical or diagnostic procedure

*          Future treatment recommendations

*          Summarizing complex medical issues or inherited complex claims

FIELD CASE MANAGEMENT

Southwest Medical Examination Services Field Case Management services coordinate comprehensive medical care in an effort to decrease disability and extended unemployment.  Our services ensure that quality medical care is provided and maximum recovery is achieved.  Our case management team establishes a good rapport and working relationship with the injured worker, family, attending physicians, legal counsel and employer.

Each Case Manager is a Registered Nurse or Certified Vocational Counselor.  These individuals are hand-picked due to their knowledge of the medical community in their territory and the industry.

Pro-active early intervention is the key to successful field based case management.  This will guarantee that superior and timely care is provided throughout the life of the case. 

Cases are referred for Field Case Management per the following criteria:

*          Catastrophic injuries                                                     *Acts of God (Fire, Tornados)

*          Burns                                                                           *Face to face evaluations

*          Brain Injuries                                                                *Home Health Care

*          Spinal cord damage                                                      *Extended hospitalizations

*          Multiple physician involvement                                      *Major Trauma

*          Claimants lacking motivation to RTW                           *language barriers                                                                                                                
*          Claimants that witness loss of co-worker