utilization & review

Reimbursement Review

Performed by a licensed Registered Nurse, knowledgeable in the appropriate application of workers’ compensation fee schedules and usual and customary databases.

  • Reviews medical records and bills to verify the appropriateness of medical services, the relatedness of those services to the covered injury of illness, and the accuracy of the billing codes based on the services provided
  • Resources utilized: The Medical Disability Advisor, Milliman & Robertson, Medicode Usual & Customary Data Base, Official Disability Guidelines, etc

Pre Certification

Performed by a licensed Registered Nurse.

  • Verifies appropriateness of medical procedures being performed
  • Assures that all medical services are performed in the most cost effective environment
  • Assures length of stay for inpatient hospital procedures is within acceptable standards
  • Monitors progress towards discharge telephonically to ensure timely discharge to home or transfer to a long term care facility when appropriate

Fee Scheduling

An experienced fee schedule analyst creates explanation of benefits outlining appropriate payment for medical services based on application of the appropriate workers’ compensation fee schedule and/or usual and customary data base.

Network & Negotiated Discounts

Access to discounts through contracts established by Midlands directly with medical providers or with preferred provider organizations and managed care organizations. Discount negation is also performed for equipment rental and other services.