Workers'
Compensation

Programs that result in savings every step of the way.

Medlogix® workers’ compensation programs offer employers an integrated proactive approach to effectively managing work-related injuries and help control escalating medical and indemnity costs. We serve as your medical claims management 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 Medlogix® case manager ensures the injured worker receives timely and medically necessary treatment 24/7 and 365 days per year.

Our Workers’ Compensation services are powered by our proprietary, web-based case management and bill review software, featuring a customizable, user-friendly platform and real-time access to the ongoing management of a claim. Progress may be tracked on nurse medical case management, case status, provider billing and RTW status. Automatic alerts are issued for a change in work status, compensability and more. Users receive individual secure logins so adjusters and case managers have access to all file activity in real-time.

Workers'
Compensation
Services

  • First Report of Injury

    Our First Report of Injury services make it easy for employers to report on-the-job injuries and initiate the workers’ compensation claims process. Medlogix® provides 24/7 claim intake via web referral, fax or phone. Additionally, we complete all state-required accident forms and submit via secure EDI to the appropriate parties. Treatment management is initiated with triage at time of injury and continues through treatment paths and facilitates timely and medically necessary treatment which is appropriate for the work injury.

  • PPO Networks/Panel Development

    A division of Medlogix®, CHN PPO is a leading preferred provider organization serving the northeastern United States with over 140,000 health care provider locations. A proprietary network with all providers directly contracted, CHN’s cornerstone is top-quality health care providers. Through these direct network contracts and a national network of PPO affiliates, CHN delivers a seamless coast-to-coast competitive edge to the clients we serve.

    Our comprehensive network is comprised of providers who specialize in the diagnosis and treatment of work-related injuries. Some of the specialties offered include primary care, occupational medicine, orthopedics, physical therapists, surgeons, urgent care facilities, hospitals and trauma centers. All providers undergo CHN’s rigorous credentialing process with re-credentialing every three years in accordance with industry standards. Provider panels are jointly created by CHN’s network development team in conjunction with clinical staff. These select providers deliver the most effective care and results for work-related injuries.

  • Telephonic Case Management

    Medlogix®’s dedicated telephonic case managers ensure medically appropriate care is rendered 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. Medlogix® 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:

    • Early identification and assessment
    • Discharge planning
    • Planning for complications
    • Identifying appropriate physician, facilities and outpatient referrals
    • Avoiding unnecessary hospital admissions
    • Negotiating appropriate rates and levels of care
  • 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 as a result of their injuries and reduced financial exposure for insurers and employers.

    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
    • Negotiating appropriate rates and levels of care
  • 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 worksite injuries. Medlogix® offers a highly credentialed panel of medical directors in all appropriate specialties, which includes numerous medical directors on-site at Medlogix®’s operations center.

  • 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.

    Services include:

    • 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
  • Medical Bill Review

    MyMedlogix™ is our proprietary. Medical Bill Review software through which all information is contained.  This leading edge technology creates a seamless, web-based platform through which all processes flow through one integrated system. With MyMedlogix™, clients can securely  and efficiently manage claim activities with real-time data 24/7. Most importantly, this platform meets all local, regional and national jurisdiction requirements.

    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™ 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
  • Code Review

    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 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.

    Services include:

    • 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
  • 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 include a worksheet which outlines eligible/ineligible charges.

  • Bill/Negotiations

    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 (IME)

    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.

    Services include:

    • 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

    A division of Medlogix®, CHN PPO is a leading preferred provider organization serving the northeastern United States with over 140,000 health care provider locations. A proprietary network with all providers directly contracted, CHN’s cornerstone is top-quality health care providers. Through these direct network contracts and a national network of PPO affiliates, CHN delivers a coast-to-coast competitive edge to the clients we serve. By partnering with select regional PPOs that meet our rigorous standards for credentialing, accessibility and cost savings, CHN offers seamless national PPO access to our clients.

  • Peer Review

    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.

    Services include:

    • 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
  • Pharmacy Benefit Management

    Through our pharmacy benefit management partners, Medlogix® 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.

    Medlogix®’s pharmacy benefit management program offers:

    • Transactional services, such as network administration, provider communications, first fill programs, card administration, POS processing, mail order, out-of-network management, call center support, payment and billing.
    • Clinical services, such as formulary management, clinical red flags, utilization review services, drug trends analysis and quality measurement.
    • Strategic services, such as customized strategy and product development, integration with bill review and outcomes measurement.