Retrospective Nurse Audit: Provides an introduction and narrative of all the medical
treatment that has occurred for a claimant. It also includes a detailed findings list
that outlines what is appropriate, what is not appropriate, and recommendations as to
which charges should be adjusted. This provides the claims analyst with an excellent tool
for negotiating specials for casualty, bodily injury, and third party claims. This product
is key in dealing with claims that have multiple treatment modalities and extensive
billing where treatment has been provided by neurologists, orthopedic surgeons, or
chiropractors over an extended period. The Nurse Audit will also indicate the appropriate
specialty area when a Peer Physician Review is recommended.
Physician Peer Review: The
product may utilize any one of ICS’ Board-Certified Physician specialists. The
review addresses pre-existing conditions, reasonable and customary charges, medical
necessity of treatment(s) provided, relatedness of treatment to the claim under review,
and the claimant’s precise medical status.
Independent Medical Exam
(IME): This product is provided by ICS utilizing its staff of physicians
throughout the country and allows for "one-stop-shopping." One phone call to ICS
initiates the process and our staff coordinates the entire IME process. ICS
notifies all involved parties (claimant, physician, and plaintiff’s attorney if
applicable) and coordinates with all involved parties as to the time and location of the
IME. Upon completion of the IME, a transcribed report is sent to the claims analyst within
five (5) business days.
RN Record Analysis: An
off-site review of all available medical records. This report provides a chronological
overview of treatments provided to claimant(s) with an analysis of appropriateness,
frequency, duration, and types of therapies documented and offers recommendations to
assist with claim or litigation settlement.
All ICS physician and nurse
consultants
will provide expert testimony as needed.
Sample copies of our Nurse
Audits and Peer Physician Review reports will be provided upon request.
MEDICAL CLAIMS PAYMENT
COMPLIANCE AUDIT
| Audit
Objectives |
The Objective of auditing procedures
applied to benefit payments for participants in the benefit plan are to provide the
auditor with a reasonable basis for concluding-
|
| a. |
Whether the amounts of the authorized payments are in accordance with plan
provisions. |
| b. |
Whether the payments are made to persons entitled to them and only such
persons (that is, the benefit payments are not being made to deceased beneficiaries or to
persons other than eligible participants). |
|
| Review and Evaluation of Governing Documents |
| 1. |
Medical Benefit Contract(s) |
| 2. |
Summary Plan Description(s) |
| 3. |
Independent Financial Statements of Insurance Co./
Third Party Administrator |
| 4. |
System of Internal Controls of the Insurance Co./
Third Party Administrator |
| 5. |
Applicable State Insurance Regulations |
| 6. |
Pre-Admission Hospital Certification Program(s) |
| 7. |
Individual Care Management Program(s) |
|
| Eligibility Verification |
| 1. |
Preliminary evaluation of procedures for adding and deleting employees and
dependents to/from coverage. |
| 2. |
Trace specific additions and deletions of covered persons to the claims
payment report to determine if payments were made on behalf of any ineligibles. |
| 3. |
Trace specific short term disability claim payments to medical claim
payment reports to determine appropriateness of claim(s). |
| 4. |
Trace specific workers compensation claim payments to medical claims
payment report to determine the appropriateness of claim(s). |
|
| Claims Payment Controls |
| 1. |
Quality Assurance/Case Management |
| 2. |
Provider Discounts |
| 3. |
Other Party Liability Recoveries |
| 4. |
Integration of Programs (Rx, Medical, STD, WC) |
| 5. |
On site hospital bill audits |
| 2. |
Summary Plan Description(s) |
|
