Auto
Medical

Consolidated Services Group supports our auto insurance clients in managing the medical costs and care for their policyholders. We offer a diverse mix of medical expertise and innovative technology that delivers a more efficient, disciplined claims handling process. Our clients can count on proficient, knowledgeable service for every claim, from initial filing through close.

Medical Ability

CSG offers a highly-credentialed team of on-site medical directors, nurse case managers and utilization managers, along with a robust, multi-specialty IME and Peer Review provider network. Our expert care coordinators ensure injured parties achieve the best possible outcomes and most effective care by thoroughly reviewing medical treatment and efficiently communicating with payors, providers and injured parties. Our CHN PPO network of highly-credentialed providers is specifically skilled in diagnosing and treating automobile injuries.

Technical Agility

CSG Services are powered by medlogix® our proprietary, web-based case management and bill review software. This seamless, end-to-end technology fully integrates all CSG services into a customizable, user-friendly platform that provides real-time access to the ongoing medical management of a claim.

Available Services

This prospective review of diagnostic tests, durable medical equipment, medical treatment and medical procedures supports auto carriers in maintaining AICRA compliance. Services may include may include prior authorization, utilization review and case management to determine whether the treatment plan is medically necessary and whether it provides for the appropriate level of care consistent with clinical protocols. Treatment that does not meet this criteria is escalated to a medical director. CSG manages the entire pre-certification process, including appeals and dispute resolution.

Our robust, multi-specialty network of IME providers delivers objective assessments to determine the medical necessity of treatment while demonstrating fairness and respect for the injured person. Our highly-credentialed network includes over 35,000 IME providers representing all relevant medical specialties. We also offer IME service in all 50 states through our coast-to-coast network of affiliate partners.

Services include:

  • Expert medical evaluations
  • Medical expert testimony
  • Registered nurse review and consultation
  • Record and chart reviews
  • Concise medical reports supported by contact/coordination
  • Immediate notification when an appointment is missed
These retrospective reviews of all treatments and services in the medical record support fair auto claims settlements by establishing causality and by assessing reasonableness and necessity of care based on established clinical protocols and national standards. The utilization review staff identifies any embellishment, fraud or up-coding and provides a thorough report on its findings, along with supporting documentation.

Requested for serious injuries and catastrophic claims, Lifetime Cost Projections (LCP) provide a comprehensive evaluation of current and future treatment needs and expected medical costs associated with the treatment plan. Case management professionals perform an extensive review of the claim file and medical history and deliver a comprehensive report, along with supporting documentation.

Services include:

  • Case assessment (Cost projections and care plan projections)
  • Medical records review
  • Case synopsis
  • Contact with injured party, necessary care givers and product suppliers
  • Evaluation of future treatment needs
  • Evaluation of future cost, life expectancy
  • Detailed report with electronic submission
  • Rated Age Life Expectancy Projection
A division of CSG, CHN PPO is a leading preferred provider organization serving the northeastern United States with over 140,000 health care provider locations. A proprietary network with all providers directly contracted, CHN's cornerstone is top-quality health care providers. Through these direct network contracts and a national network of PPO affiliates, CHN delivers a coast-to-coast competitive edge to the clients we serve. By partnering with select regional PPOs that meet our rigorous standards for credentialing, accessibility and cost savings, CHN offers seamless national PPO access to our clients.
A Certified Nurse will perform desktop or onsite hospital and provider auditing and review records to ensure all services billed are causally related and properly documented. CSG requests all pertinent information necessary for the review (provider bills, medical authorizations and medical records). Results are documented and recommendations made for payment.
For cases that require a physician review to determine medical necessity, CSG provides access to highly-credentialed medical directors to provide professional guidance regarding the appropriate treatment of automobile injuries. CSG maintains a full staff of multi-specialty medical directors in all appropriate specialties, which includes numerous medical directors on-site at CSG's customer service center. CSG's technology-enabled medical director review services deliver complete and defensible recommendations. Our robust medlogix® technology distills multi-page medical record documents into one digital file that is easy to access, read and utilize. The result is a more efficient process, increased accuracy, more complete and defensible information, and a more positive interaction with the treating provider.

When a face-to-face evaluation is not required or possible, our network of fully credentialed and board certified physicians can provide a retrospective review of treatment to quickly and competently determine whether care provided was medically necessary and causally related. Our panel of physicians are required to have their own functioning practice and must be willing to testify in the event of a dispute.

The end product will include:

  • Quality assurance review by a nurse to ensure all questions have been answered and clinical documentation has been used
  • Conclusive determinations on the issues of medical necessity and causality
  • Turnaround time of 5-7 business days
  • Full compliance of all state regulations

The direct oversight of a medical professional provides valuable guidance for complex or catastrophic cases, or those that are not progressing as expected. Nationally certified registered nurses (CCM and/or CRRN) with three to five years of catastrophic case management experience assess and coordinate treatment by working with medical care providers, employers, attorneys, injured persons and their families to ensure quality health services are delivered in a cost-effective manner. The result is decreased hardship to individuals and their families/significant others as a result of their injuries and reduced financial exposure for insurers and self-insurers.

Case management is directed toward:

  • Early identification and assessment
  • Discharge planning
  • Planning for complications
  • Identifying appropriate physician, facilities and outpatient referrals, avoiding unnecessary hospital admissions, and negotiating appropriate rates and levels of care

CSG provides a highly advanced bill review system powered by medlogix® -- our proprietary, web-based platform for managing claims information. This seamless, integrated platform provides real-time claims data 24/7 and meets all local, regional and national jurisdiction requirements. Utilizing this powerful system, CSG bill reviewers evaluate the diagnosis relationship, medically necessary treatment and properly coded billing patterns against the corresponding covered loss. medlogix® automatically scans for duplicates and matches treatment codes to actual documented treatment. The bill reviewers utilize this technology to identify improper coding or billed services that may require further scrutiny. Where appropriate, they reprice provider, facility and ancillary service bills. They also apply preferred provider adjustments or, if preferred provider discounts do not apply, refer bills for out-of-network negotiations. The result is the utmost in efficiency and savings for our customers.

medlogix® software employs the following automated analyst edits for all applicable state medical fee schedules and rules, including the following:

  • Current and past state-specific medical fee schedules by regions
  • Applicable PPO fee schedules by region
  • Applicable U&C calculation schedules, where appropriate
  • Multiple procedure reduction formula calculations
  • Modifier calculations
  • Trauma facility flags
  • Policy limit flags
  • Deductible and co-payment calculations
  • Interest calculation
  • Crosswalks (correction of invalid code to a valid code, V-codes, ICD-9, NDC and CPT)
  • NCCI edits
  • Duplicate bill and line checking indicators

A CSG coding professional reviews the CPT-4 and ICD-9/ICD-10 coding of outpatient services by physician, diagnostic, therapeutic, and durable medical equipment companies to assess and resolve inappropriate billing practices. CSG's code review services are performed by a team of highly skilled registered nurses with years of coding experience. Codes requiring review can be customized based on client needs and are triggered during the bill review adjudication process to ensure provider billings are not unbundled, fragmented, up-coded, unrelated or otherwise improperly coded according to national or regional billing practices. When a provider bills with modifiers, the coding professional reviews the documentation to confirm the use of the modifier is supported, adjusting the provider bill and removing the modifier, where necessary.

Services include:

  • Full review of HCFA 1500 or UB92 and associated medical records
  • Detailed revision of medlogix® EOR
  • Provider contact (if necessary)
  • Response to provider if rebuttal to assessment decision occurs

Bill negotiations reduce the costs of medical bills from providers and facilities not participating with a provider network for total cost management. The negotiation team proceeds with a review of UCR, Medicare, claims utilization history and in-network payment rates to aggressively negotiate with non-network hospitals, physicians, and ancillary health care providers to reduce costs.

CSG's Bill Negotiation program includes:

  • Direct negotiations by experienced, highly-skilled negotiators with expertise and knowledge of rate levels
  • All negotiations are confirmed with signed Letters of Agreement from providers
  • Average savings of 22-24% below standard bill review reductions
  • High acceptance rate – average of 70%
  • Prospective and retrospective negotiations
  • Customized referral criteria