Pre-Certification: Medlogix case managers conduct pre-certifications in accordance with each customer’s plan to assess medical necessity and duration of care while ensuring consistency with clinical protocols. 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.

Utilization Management: We offer both retrospective and concurrent utilization management services designed to provide high-quality, well-managed care while reducing unnecessary claims costs. This highly-experienced team, which includes Medical Directors, Specialty Physician Advisors, Nurse Case Managers and Utilization Review nurses, works closely with providers to confirm that treatment plans meet the level of care for optimum outcomes.

Large Case Management: Case Managers specialize in managing high-risk, high-dollar claims, including cardiac disease, transplants, high-risk maternity with neonatology, oncology and behavioral health intervention. Effective management of these serious or catastrophic cases can have a significant positive impact on the outcome.

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.

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

All negotiations are confirmed with signed Letters of Agreement from providers

High acceptance rate – average of 70%

Prospective and retrospective negotiations

Customized referral criteria

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, and negotiating appropriate rates and levels of care

CHN PPO Group Health | Medlogix

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