Our URAC certified Utilization Review Process is the catalyst that allows the team to excel in the management of the delicate balance between clinical and administrative care of the claim.  Through our web based technology platform and our proven expertise with new utilization review reforms we continue to provide injured and ill workers with a management team of highly skilled, like-minded health care professionals and a team of proactive administrative personnel.

UTILIZATION REVIEW

We offer prospective, concurrent, and retrospective utilization review in accordance with California Regulations Labor Code section 4610.  Preferred adheres to the Medical Treatment Utilization Schedule (MTUS) adopted by the Administrative Director (AD) of the Division of Workers' Compensation and the American College of Occupational and Environmental Medicine Practice Guidelines (ACOEM).  We make treatment recommendations utilizing medically based criteria to ensure a cost-effective treatment plan is in place.

Preferred provides customized solutions that ensure the best clinical practice methods for injured workers while reducing costs of medical care.  Our efficient web-based utilization review system allows our medical staff to focus potentially expensive time and attention only on situations that require their expertise, while technology, effectively executes all necessary administrative and regulatory tasks.  This has resulted in a streamlined system that generates the most efficient medical review in a timely and highly cost efficient manner.  This means that our technology allows your utilization review services to be executed primarily by Qualified Physicians.  The bottom line is that you will get this very necessary medical cost containment service better and faster than you would elsewhere.  Through focused utilization review technology, our utilization review nurses and specialty team are able to focus heavily on our level of customer service.

INTEGRATED UTILIZATION REVIEW/TELEPHONIC CASE MANAGEMENT

Preferred bundles together utilization review and telephonic case management to offer a symbiotic service that insures accuracy and timeliness:

• Claims wherein surgery is anticipated or recommended
• Requests for MRI, CT Scan, Discogram, Bone Scans, etc.
• All cases with OVER 14 days anticipated disability
• Chiropractic/Physical therapy treatment
• Inconsistent medical findings
• Multiple treating Physicians
• Pre-existing conditions:  Diabetes, Hypertension, Heart Disease
• Patient with history of Drug/Alcohol abuse
• Continued treatment by non-specialist beyond 45 days
• Any unusual claim in which the claims examiner feels it may warrant further intervention.

TELEPHONIC CASE MANAGEMENT

An early intervention, short term cost containment service which coordinates care and facilitates safe and timely return to work.  It is most effectively used immediately following injuries.  Our Telephonic Case Management (TCM) professionals are highly effective in evaluating the severity of injuries, negotiating medical costs and identifying opportunities for early return to work:

• Obtain medical and employment histories
• Establish the estimated extent and duration of disability
• Determine treatment goals through Physician contact
• in-patient hospitalization cases for alternative discharge plans and discuss these options with the patient and Physicians
• Locate specialty providers and coordinate referrals to them
• Negotiate cost of services, including surgery, in-patient treatments, home care, transportation, durable medical equipment supplies, and out-patient treatments, including Physical, Occupational therapy, and Chiropractic care
• Contact employers to obtain job requirements for clients with work-related injuries to determine employment status, the physical demands of the injured employees job and opportunities for modified or alternative duty
• Facilitate communication between physicians and employers to coordinate early return to work

FIELD CASE Management