MEDICAL BILL ADJUDICATION SERVICES

Millennium Risk Managers provides to large self-insured entities and insurance carriers operating in the State of Alabama medical bill adjudication services.

Millennium Risk Managers’ bill adjudication contract reduction foundation is built upon the AlaMed PPO, which is the largest workers’ compensation PPO in the State of Alabama.

Millennium Risk Managers is a founding member of the AlaMed PPO.

Millennium Risk Managers offers bill adjudication opportunities, whereby the account can adjudicate medical bills internally and produce their own EOBs, or Millennium Risk Managers will adjudicate the medical bill and produce the EOB and electronically transfer that EOB back to the account for payment of the reduced medical bill.

Over the past 10 years, Millennium Risk Managers has processed approximately $1 billion in medical bills and this PPO adjudication system has produced “real dollar medical bill savings” of approximately $250 million back to the accounts.

On average, this PPO medical bill adjudication produces approximately 25% off of billed charges. Depending upon the particular medical bill category (medical office visit, laboratory, hospital, etc.) the savings can be higher.

SYSTEM OVERVIEW

Basically, this adjudication system allows the account to produce an EOB that is based upon the lower of the Alabama State Fee Schedule or AlaMed.

This system allows the account to capture the “real dollar savings” based upon pre-negotiated bill reduction contracts to produce a reduced net bill upon which payment is made back to the vendor.

The system produces the EOB which indicates back to the medical vendor which contract the bill was adjudicated so that the vendors’ accounts receivable department is put on notice as to the contract adjudication amount.

ALAMED PPO

Originated in 1991 by five Self Insurance Service companies to provide a value-added service to their large associations and self-insured customers, the AlaMed PPO has consistently delivered additional savings in excess of 15% (and up to 25% or more) above and beyond the Alabama State fee schedule. AlaMed associations and self-insureds refer their injured employees to the AlaMed healthcare providers in order to receive the best level of pricing available in Alabama.

The AlaMed Workers’ Compensation PPO contains the best doctors and highest quality healthcare providers who are committed to healing injured workers and returning them to work. AlaMed receives the best level of pricing from providers in exchange for the employer’s steerage of injured workers.

AlaMed is committed to planned growth of its employer base. Each prospective payer is evaluated on the basis of its commitment and ability to refer injured employees to AlaMed healthcare providers. Call us to see if your company qualifies to participate in the AlaMed Workers’ Compensation PPO.

AlaMed is devoted to supplying our members, self-insured companies, group pools and self insured trusts…with the best providers, at the most economical rates in the industry. Savings of 10% to 25% are accomplished through front end direction of injured workers and producing reportable positive outcome for our clients as well as their employees. AlaMed currently serves over 10,000 employers and their employees through 76 hospitals, hundreds of physicians, pharmaceutical programs and countless numbers of other providers. Our providers have been selected for inclusion in our network because they understand the value of “early intervention” in the work comp claims process.

AlaMed Providers truly understand the long term value in the work comp claims process by implementing effective “Return to Work” programs. Our contracted providers are participants in our “Industry Treatment Protocols Systems” which deliver better control and reduced cost to the customer. Through AlaMed, “customized provider panels” can be achieved for better communications with the clients and end users of AlaMed.

Provider Types

  • Anesthesiologists
  • Cardiology
  • Case Managers
  • Chiropractors
  • Chronic Pain Programs
  • Dentists/Oral Surgeons
  • Dermatologists
  • Diagnostic
  • Durable Medical Equipment
  • ENT
  • Gastroenterology
  • Hematology/Oncology
  • Home Health
  • Hospitals
  • Internal Medicine
  • Neurology/Neurosurgeon
  • Ophthalmology
  • Orthopedists
  • Orthotics and Prosthetics
  • Pain Medicine
  • Pathology
  • Physical Therapy/Rehabilitation
  • Physicians
  • Plastic & Reconstructive Surgery
  • Podiatry
  • Psychiatry
  • Pulmonologist
  • Radiology
  • Surgeons
  • Translation
  • Transportation
  • Urology
  • Vascular Surgery

SURGEON BILL UNBUNDLING

Millennium Risk Managers offers medical bill “unbundling” services, whereby the surgeon’s operating bill is broken down into its component billing sub-parts for proper application of the various state fee schedule and AlaMed fee schedule as it applies to surgeons and assistant surgeons.

This “unbundling” provides for assurances that the surgeon’s operating bill is adjudicated to maximize the proper contractual adjudication fee savings.

SURGICAL IMPLANTS

Millennium Risk Managers offers a surgical implant specialty “carve out” contracts, whereby the account pays the manufacturer’s cost of the implant plus a percentage.

This adjudication service assures the account that “surgical implants” are not billed by the hospital with over-inflated mark-ups back to the account. This system also gives the account control over specific surgical costs that are associated with the high-end medical expense exposure processes.

BIDDING SYSTEM

Millennium Risk Managers’ adjudication system provides a unique feature pertaining to various vendors that are necessary in the administration of a workers’ compensation claim.

This program provides to the account a system whereby selected industry vendors must “bid” on each job that the account must place on a file for optimum claims administration.

When the account needs one of these vendor’s services on a file, they go into the “bidding system” and put out to these vendors the request for a quote and these vendors, daily, job by job, bid on that vendor request.

This gives the account ultimate assurance that it is receiving the market’s lowest negotiated rate per day, by job.

The industries that are put within this “bidding system” are:

  • Travel
  • Medical Durable Supplies
  • Diagnostics
  • Home Healthcare

Each of the above industries’ providers are AlaMed vendors, which gives assurances as to the quality of care that each vendor provides and each vendor is an Alabama based entity, which allows for the account to have immediate vendor communication for any specialty needs or issues and it allows for the claims dollar to remain within the State of Alabama to assure that the vendors within this program remain in business for the long duration as needed on the workers’ compensation files’ lifetime cost.

UTILIZATION REVIEW

Millennium Risk Managers provides a specialty utilization review program that entails combining the traditional utilization review programs with local Alabama specialized physicians, which are DIR Form-50 UR Certified, that function in the UR process at the Alabama UR Administrative Rules Level 2 review.

The overall result of this specialty placed UR program allows for the account to have local physicians testify live at trial on any “Motions to Compel Treatment” that arises in cases where UR has denied a medical treatment modality versus having a foreign doctor’s UR report produced in the courtroom.

The affect of this specialty program gives the account assurances that its UR program denial decisions have the best chance of being upheld before the Alabama Trial Court.

RX UTILIZATION REVIEW

Millennium Risk Managers provides a highly specialized RX utilization review program whereby pain management pharmaceutical prescriptions are put through the Alabama Utilization Review procedures for the determination of medical necessity.

This program places DIR Form-50 UR Certified pharmacologists and physicians on a Level 2 UR panel who reviews these RX prescriptions issued out on the account’s pain management files.

These physicians/pharmacologists practice in the State of Alabama and testify live in the courtroom on “Motions to Compel Treatment” where the UR denied or limited certain RX prescriptions.

Millennium Risk Managers also offers, through an RX vendor, a pharmaceutical cost containment program whereby the account’s claimant is provided an RX card that can be used a virtually every pharmacy in the State of Alabama and automatically produces huge savings over the Alabama RX Fee Schedule. Most importantly, this RX cost containment system also allows for the account to “go into ” the RX maintenance company and place the UR limitations or blocks directly onto the specific claimant’s RX card to assure that the RX UR decisions are implemented to assure a systematic reduction based upon the RX UR decisions.

TREATMENT UTILIZATION REVIEW:

MRM offers a comprehensive Treatment Utilization Review platform.  When a specialist wants to perform a treatment and we do not think it is reasonable or medically necessary, we send the treatment request to a Treatment Utilization Review Program.  This panel of experts, who review the treatment request are board certified, practicing physicians in the State of Alabama and include every specialty from a neurosurgeon, orthopedic surgeon, neurologist, to pain management doctors, etc. If a pain management doctor, for example, wants to do another block on a claimant, that block is sent in for Treatment Utilization Review.  If it is deemed unreasonable or not medically necessary, it will be denied and that denial is backed up by Alabama certified doctors, which is a very important part of the platform, especially during litigation.

PAIN MANAGEMENT

Pain management has become one of the more prevalent treatment components on a work comp claim.  After the employee has had surgery, they are traditionally referred to a pain management doctor for lifetime care; whereby, they obtain their pharmaceuticals for life.  The pain management doctor may then prescribe procedures, and perform those procedures, or he might prescribe pharmaceuticals and dispense those pharmaceuticals all within a one-stop, one-shop component.  Unfortunately, there is the potential for profit motive at that point, so MRM has developed a new Pain Management platform that takes that potential out of the process.  We have a gatekeeper to whom the doctor refers the employee, and that gatekeeper assesses the need for pharmaceuticals and assesses the need for treatments, such as blocks.  If the employee needs a pharmaceutical, he is referred to a salaried, prescribing doctor who works for the University of Alabama in Birmingham.  When this doctor writes that prescription, he will electronically file it with one of the participating pharmacies in the State of Alabama.  The employee must go to that pharmacy, which is local to the employee, to obtain the particular prescription.  If the gatekeeper determines that the employee needs a block, then he refers that employee to the pain management center at UAB where salaried doctors perform the procedure.  After treatment, the employee is referred back to the gatekeeper.  We provide a true treatment platform, which is in the best interest of the employee, while mitigating the potential profit motive of treating physicians or treatment facilities.

MEDICARE SET-ASIDES AND MEDICARE RECOVERY PROGRAMS

MRM offers an advanced program management platform to navigate its clients through the complexities of the Federal government’s Medicare Set-Asides, the Medicare Recovery Programs and their traditional payment lien letters.  To address these major areas of concern, MRM retained and brought in house an attorney certified in Medicare Set-Aside consultations.  He is only one of 17 certified in the State of Alabama.  He runs and manages the entire Medicare Set-Aside program and the traditional payment lien programs for our clients.

For example, in order to close out your old medical files in pain management, you have to use a Medicare Set-Aside Agreement.  The problem is that most of these old claimants are already on Medicare, so when you do your pharmaceutical or treatment Utilization Review on these pain management files, you might discover that a doctor is continuing to prescribe pharmaceuticals or treatment to an employee, notwithstanding that they have been blocked, and continuing to bill Medicare, which, in turn, is continuing to pay them.  When you try to settle this employee’s medical benefits, you have to use the MSA Program, which is a standard program whereby you get value for that case through Medicare by buying an annuity to fund that buy out.  Once annuitized, and settled through the court with the MSA is intact, Medicare will send a conditional payment lien letter requesting reimbursement for all the money they paid on behalf of that claim to the pain management doctor, whether it was pharmaceuticals or procedures.  You will be financially responsible for all the unauthorized treatments if you do not file the proper objections within 30 days.  Our staff attorney monitors and responds to all those conditional payment liens on behalf of our clients.

This is the most predominate area for concern for any self-insured account, trade association or any insurance carrier dealing with Medicare and the Federal government over the next five years.  If you are not on top of the regulations and requirements and have not implemented cost containment program management, you could be required under the Medicare Recovery Act to go back to files that have been closed and be forced to reopen them and pay Medicare for all those treatments that you blocked or did not pay for, but that the doctors submitted to Medicare for payment.  You will be financially responsible for all those payments that Medicare made plus penalties and fines.  When your actuaries see this, they are going to increase your IBNRs (Incurred But Not Reported) and you could be bankrupted.  It will be a domino effect, and the Federal government will enact a National Work Comp Act where all the benefits are now paid by the Federal government and there will no longer be any self-insured work comp.  MRM can help you to prevent such a calamity, if you are proactive and implement our program management platform now.

MRM is the only TPA in the Southeastern United States that has a specialized staff attorney whose sole responsibility is to provide this program management platform.  If you want to really protect yourself and implement advanced program management, we will take your old pain management files from 2004 and back and bring those files into a Medicare Set-Aside program, fund them with annuities, and get out 60 percent of the reserves.  We will actually utilize the Medicare Set-Aside statutes as a partial loss portfolio transfer for our larger accounts.  Now that is very advanced program management.