Better managed medical costs and care for policyholders.
Our internally-developed MyMedlogix™ software integrates and organizes complex medical claims management workflow into one common platform built on modern Microsoft.NET architecture. MyMedlogix™ is the central hub through which all medical claim management activities and resulting workflows can be ordered, tracked and documented. In contrast to competing point solutions, MyMedlogix™ enables streamlined management of all critical elements of the medical claim, from bill review and auditing to IME, nurse and medical director review and medical management claims handling. MyMedlogix™ is web-based as well as client server-based and fully customizable, offering clients encrypted, HIPAA-compliant access to real-time medical claims data on a 24/7 basis. The platform can be configured to carrier specifications and, importantly, to comply with all local, regional and national jurisdictional requirements. The intelligence, rules and functionality of MyMedlogix™ have been created with over 30 years of company experience and are continually updated to reflect current industry needs, making MyMedlogix™ one of the most robust technology solutions in the medical industry.
MyMedlogix™’s differentiated proposition combines medical expertise, proven processes and innovative technology solutions to deliver a more efficient, disciplined medical claims process to leading property and casualty (P&C) carriers. In particular, MyMedlogix™ is widely recognized for its deep expertise, focus and experience in the automotive medical market.
Medical claims management is complex, requiring a myriad of workflows to ensure proper, timely care is delivered and accurately reimbursed while complying with regulations that differ state-by-state. Medlogix® offers an end-to-end suite of medical claims management and cost containment solutions, orchestrated through the company’s proprietary MyMedlogix™ software, which vastly improves medical claims management while mitigating P&C carrier liability.
Medical Bill Review
MyMedlogix® is our proprietary fully-integrated Medical Bill Review software through which all information is contained. Our proprietary technology creates a seamless, web-based platform through which all processes flow through one integrated system. With MyMedlogix, clients can efficiently and securely manage claim activities with real-time data 24/7. Most importantly, this platform meets all local, regional and national jurisdiction requirements.
MyMedlogix is a paperless workflow-based model that controls user access by role and provides a consistent monitored environment for all work. The MyMedlogix integrated solution is a single system that allows the client to have a transparent mailroom, scanning and integrated data capture solution. MyMedlogix contains several robust rules engines that can be customized to support client-specific needs such as by coverage, location, adjuster, SIU, etc.
The MyMedlogix integrated solution allows us to reprice provider, facility and ancillary services bills while determining diagnosis relationship, medically necessary treatment and properly coded billing patterns against the corresponding covered loss; thus maximizing efficiency and savings to our customers.
MyMedlogix software employs the following automated analyst edits:
- Current and past state-specific medical fee schedules
- Applicable PPO fee schedules
- Applicable U&C calculation schedules
- Multiple procedure reductions
- Modifier calculations
- Trauma facility flags
- Policy limit flags
- Deductible and co-payments
- 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
Medical Bill Auditing
Medlogix® has a dedicated team of registered nurses who perform extensive reviews of facility and provider bills to ensure all services billed were appropriately documented and causally related to the claim. Depending on the need, audits can be performed at a desktop level or on-site at the provider facility. Our team of health care professionals use their years of training and medical expertise to review records to verify all billed services are properly supported in the documentation provided. Documentation is also reviewed to confirm that all treatment rendered was as a result of the accident and not a pre-existing medical condition that would not be the responsibility of the insurer. The audit process also includes the application of all state regulatory requirements and application of any appropriate fee schedule.
Audit results are compiled and presented in a detailed narrative report and includes a worksheet which outlines eligible/ineligible charges.
A Medlogix® 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. Medlogix®’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 need 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.
- 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
Medlogix® delivers national access to PPO network providers who are highly skilled in diagnosing and treating automobile and workplace injuries. This begins with our proprietary flagship CHN PPO, which is a leading preferred provider organization serving the northeastern United States with a premier, highly-credentialed network of over 140,000 provider locations. By partnering with select regional and national PPOs that achieve high levels of credentialing, accessibility and cost savings consistent with our rigorous standards, Medlogix® delivers a coast-to-coast competitive edge to the customers we serve.
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.
Medlogix®’s Bill Negotiation program includes:
- Direct negotiations by experienced, highly-skilled negotiators with expertise and knowledge of rate levels
- Signed Letters of Agreement from providers
- Prospective and retrospective negotiations
- Customized referral criteria
Independent Medical Exams
Medlogix® 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.
- 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
Medlogix’s comprehensive Peer Review network spans all provider types and delivers a like- specialty, retrospective review of provider billed treatment to determine whether care provided was medically necessary and causally related. Medlogix® utilizes credentialed specialists who are board certified in the same specialty as the requested medical review. Findings are documented in a detailed narrative report of all provider findings.
Peer Review providers are required to have their own functioning practice and must be willing to testify in the event of a dispute.
- Quality assurance review by a nurse to ensure all questions have been answered and clinical documentation has been cited
- Conclusive determinations on the issues of medical necessity and causality
- Turnaround time of 5-7 business days
- Full compliance of all state regulations
This prospective review of diagnostic tests, durable medical equipment, medical treatment and medical procedures supports auto carriers in maintaining NJ-AICRA compliance. Services 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. Medlogix® manages the entire pre-certification process, including appeals and dispute resolution.
Medical Director Review
For cases that require a physician review to determine medical necessity, Medlogix® provides access to highly-credentialed medical directors to provide professional guidance regarding the appropriate treatment of automobile injuries. Medlogix® maintains a fully credentialed staff of multi-specialty medical directors in all appropriate specialties, which includes numerous medical directors on-site at Medlogix®’s operations center. Medlogix®’s technology-enabled medical director review services deliver complete and defensible recommendations.
Field Case Management
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
Lifetime Cost Projections
Requested for serious injuries and catastrophic claims, Lifetime Cost Projections 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.
- 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
MyMedlogix® Technology and EDI Capabilities
Through the MyMedlogix portal, carriers have a single source for claim submission, provider look-up, customer service, claims tracking and provider nomination process. Medlogix® delivers custom electronic data interchange (EDI) solutions to connect business partners’ applications with our proprietary Medlogix® software. Using our secure, automated process, business partners enjoy real-time processing of the most current PPO network data available. Our wide range of interface options include Web-services, XML and 837 formats.
Third Party Professional Reviews
Medlogix’s solution for handling Third Party Demand Packages provides knowledge and attention unmatched in the industry.
Medlogix provides an integrated solution through a combination of our proprietary MyMedlogix® medical claims management software and our medical and professional expertise.
Medlogix’s Third Party Professional Review services provides the tools to more effectively negotiate settlements with defensible supporting documentation.
Third Party Professional Review Services:
- Service options include the following:
- Medical Bill Review
- Medical Bill Audit
- Peer Review
- Litigation Support
- Professional Testimony
MyMedlogix Program features include:
- A secure web-based portal for on-line referrals
- The ability to scan and store all documents associated with the referral online
- 24/7 access to information to track activity in real time
- Two way, secure claim messaging system
- Electronic messaging alerts for important status updates
- Access to comprehensive on-line report packages