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TMC
Medical Case Management is defined as the
establishment and coordination of a treatment
plan that is medically appropriate and to
enforce the application of the treatment
plan through Bill Review component. We are
committed to improving the quality of care
and controlling costs while managing treatment
to ensure optimum outcomes.
TMC is able to provide our clients with
medical case managers in order to maintain
contact with employees, doctors, claims
professionals to control medical utilization,
obtain enhanced injured employee compliance
with optimal treatment protocols, and expedite
return to work.
TMC staff conducting Case Management consists
of professional, experienced Workers' Compensation
Medical Case Managers who are well known
in the industry, have a valid nursing license,
minimum of 3 years of Workers’ Compensation
experience, 5 years related clinical experience,
and comply with California workers’ compensation
utilization review regulations.
TMC will:
Treatment Guidelines
All of our treatment recommendations are
made utilizing the following medical based
criteria to ensure a cost effective treatment
plan is in place.
The treatment protocols utilized are professionally
recognized standards of care and are updated
to be consistent with current treatment
trends.
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Utilization
Review
TMC offers pre-certification and concurrent
utilization review in accordance with
Title 8, California Code of Regulations
9792.6. We make treatment recommendations
utilizing medically based criteria to
ensure that a cost effective treatment
plan is in place.
The TMC pre-certification program includes
verification of the medical necessity
of the proposed treatment plan. The TMC
staff of nurses, assisted by nationally
accepted medical guidelines/protocols,
along with the Medical Consultants, individually
evaluate every pre-certification request.
Click on
the link at right to see Utilization Review
criteria.
Early Intervention/Telephonic Case
Management
TMC offers Early Intervention/Telephonic
Case Management, with an emphasis on return
to work. Through early involvement in
an injury we are able to minimize medical
and indemnity costs to achieve best recovery
and return to work outcomes. Greatest
cost savings are achieved when all reports
of injury are reviewed or at a minimum,
all lost time cases within 24 hours from
receipt of notice of claim. Utilization
Review is included in Early Intervention/Telephonic
Case Management.
The TMC program has been successful in
working with individual departments to
place injured workers in modified work
settings that accommodate both the department
and employee needs. It has been successful
in dramatically dropping the Workers’
Compensation costs by avoiding litigation
and successfully returning injured workers
to modified duties.
Click on
the link at right to see Telephonic Case
Management criteria.
Field Case Management
This is the highest level of intervention
which includes direct face to face contact
with the physician, facilities and the
claimant. The FCM serves as the critical
link coordinating all activities to ensure
the appropriate medical care is received
in a timely and cost effective manner.
Click on the
link at right to see Field Case Management
criteria.
Peer Review
The Peer Reviewer/Medical Director reviews
the information from the requesting provider.
If the Peer Reviewer/Medical Director
agrees with the treatment plan based on
medical criteria or discussion with the
provider a recommendation letter to certify
is issued. If an alternate treatment plan
is agreed upon with the requesting provider
and the Peer Reviewer/Medical Director
this is also outlined in the recommendation
or certification letter. The case is then
returned to the Medical Case Manager for
concurrent review.
If the Peer Reviewer/Medical Director,
after the review with the provider, still
is unable to agree with the requested
treatment plan, based on peer-to-peer
discussion/guideline review, a letter
not to certify is issued by the Peer Reviewer/Medical
Director to the requesting provider, Medical
Case Manager and the Claims Examiner.
The appeals process is explained
Medical cost management services are integrated
into our overall claims management process
to ensure a cost-effective workflow. Case
Management nurses may be utilized to manage
injuries, which result in prolonged utilization
of medical services or the use of high
cost or specialized facilities. Case management
allows the opportunity to proactively
manage these cases.
Medical case management is integrated
into the overall claims management process
by providing the claims adjusters and
nurses access to each other’s notes via
the claims system, as well as access to
each other for immediate consultation
and strategy development on a claim. TRISTAR
believes that by giving the nurses and
claims adjusters the ability to discuss
claims with each other and review notes
when needed makes for a more cooperative,
effective and integrated claims process.
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Assist our clients in developing custom
tailored criteria to meet
