Utilization Review Services

Workers' Compensation medical costs have been escalating over the past several years. So much so that in many instances, medical expenses now outweigh indemnity costs. Utilization is one of the key factors contributing to these rising medical costs. MediCall's Utilization Review program will assist you in mitigating rising medical expenditures due to overutilization while ensuring appropriate quality care is delivered promptly. Our utilization review plan is fully compliant with URAC and jurisdictional standards. MediCall's US-licensed RN staff provides service in all states. We partner with a nationwide provider of peer review services with over 600 board-certified, US-licensed, practicing medical professionals.

MediCall UR services provide:

• Prospective review
  
• Concurrent review- including in-patient length of stays
  
• Retrospective review
  
• Appeals
  
• Reconsiderations
  

Our goal is to ensure the prevention of overutilization of medical treatment through the application of nationally recognized evidence-based guidelines thereby controlling unnecessary medical costs.

MediCall's state-of-the-art technology ensures timely and consistent decisions are delivered with required jurisdictional language in all communications. We are able to integrate our UR software decisions with your claims systems for prompt delivery of UR determinations to your claims staff. Our UR team also has the ability to work in your utilization review software to provide support for specific jurisdictions, for vacation/absence coverage, or to cover overflow during times of increased referral volume. Our quality assurance program ensures the highest degree of compliance with regulatory processes and consistent sound clinical determinations based on medical necessity.

Our Process
When a utilization review request is received, it is assigned to an experienced UR nurse for initial review. The UR nurse will review the medical data and compare to nationally recognized evidence based guidelines and determine if the treatment is medically necessary. If the treatment is found to be medically necessary, the UR nurse will issue the approval and send required notification to all parties. If the UR nurse cannot approve treatment based on the initial review, the request is sent to a physician reviewer for handling. The physician reviewer will attempt to contact the treating physician for a peer to peer discussion and after reviewing the facts of the case, make a determination. The UR nurse issues the physician reviewer's determination and sends required notification to all parties.

UR Support
MediCall can also provide utilization review support services performed by our nurses using your software. Utilizing this service enables your UR team to become more efficient and effective by off-loading some of the more administrative tasks in the UR process such as:

• Request for medical reports
• Preliminary review and setup of the UR case
• Documentation of medical findings
• Preliminary application of guidelines
• Notification of UR determination
  

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