CSG's Workers' Compensation programs offer employers an integrated, proactive approach to managing work-related injuries and controlling costs. CSG serves as a managed care and PPO partner, guiding each case to optimal MMI and RTW outcomes. From the time of injury through the end of the treatment path, the CSG case manager ensures the injured worker receives timely and medically necessary treatment 24/7 and 365 days per year. CSG's Medical Management programs result in savings throughout each facet of delivery.
CSG's proprietary program of nurse assessment, care coordination and cost projections delivers efficient, cost effective recovery. Nurses coordinate all care through our CHN PPO network, which offers highly-credentialed providers specifically skilled in diagnosing and treating workplace injuries. The network includes providers in all medical subspecialties, home care, support services and inpatient and outpatient facilities. We can also develop customized provider panels targeting specific geographic locations according to client objectives.
With CSG's proprietary medlogix® software, claims professionals can access the ongoing medical management of a workers' compensation file in real time, tracking step-by-step case progress for services such as nurse medical case management, case status, provider billing and IME status. Nurses and claims managers communicate online in real time, receiving automatic alerts when there is a change in work status, compensability or other relevant item. Each user receives a login and password to access the software, and case-specific alerts appear when logging in so both the adjuster and case manager are aware of each other's activities on the file.
Three ways to report an injury:
Please remember to have the following information when reporting:
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:
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.
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:
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.
CSG's dedicated telephonic case managers ensure medically appropriate care by assessing medical needs and evaluating treatment options. Treatment management is initiated with triage at the time of injury and continues through all treatment paths. Outcomes are measured by comparing nationally accepted guidelines. Nurse case managers provide constant communication with the adjuster, treating provider, employer and injured worker. CSG physician advisors and nurse case managers gather data, share information and provide ongoing assessments. Their clinical assessment is compared to that of the treating provider and variances are discussed. A proactive course of treatment is mutually agreed upon and an appropriate return-to-work program is implemented through a cooperative team effort.
Case management is directed toward:
Through our pharmacy benefit management partners, CSG offers a complete solution for prospective, concurrent and retrospective prescription management that helps our clients manage prescription drug costs, ensures adherence to approved guidelines and provides claimants with convenient access to medications. Our integrated approach to clinical management identifies key opportunities to reduce the total pharmacy costs. Combining health care expertise with advanced technology, we help injured people return to health and make the adjuster's job easier.
CSG's pharmacy benefit management program offers:
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.
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:
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: