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Utilization Review

OMCA is an approved vendor for Utilization Review and Medical Fee Audit in Kentucky and Utilization Review in Indiana.

URAC

OMCA provides a review of proposed or delivered medical services to determine the medical necessity and appropriateness. Our registered nurses issue approvals based on ODG Criteria which is nationally recognized. Our physician advisors use their medical judgment as well as published criteria to issue medical denials. OMCA maintains a Physician Peer Review Panel to have available the services of sufficient numbers of Kentucky-licensed and board certified physicians in appropriate specialty areas to assure adequate review of medical, surgical specialty and subspecialty cases.

Complex Case Review

OMCA ClaimsCLEAR® - Complex Loss Evaluation, Assessment & Recommendation ClaimsCLEAR® offers a scientific, evidence-based and multi-disciplinary approach to prevent, minimize and control catastrophic workers’ compensation and chronic pain claims.

Complex or catastrophic claims drives 80% of all claims expense and consume critical company resources. Furthermore, the impact of these claims can be magnified by turnover in claim personnel and the complex nature of maintaining organized medical records over a long period of time.

ClaimsCLEAR® intervention is essential for:

Post-award cases with significant on-going medicals
Multi-issue cases
Multiple prescriptions/prescribers
Active pain treatment
Long term controlled substance treatment

ClaimsCLEAR® solves complex cases and can provide:

Prediction and early identification of claimants with addictive tendencies and losses with catastrophic cost potential
Protocols to modify, minimize or eliminate ineffective, inappropriate or costly chronic drug and pain management treatment
The latest scientific data for cost effective and optimal outcome treatment plans
Objective evaluation, assessment and remediation recommendations for complex and chronic claims.

The ClaimsCLEAR® collaborative panel of Board Certified Physicians and medical consultants has distinction and superior experience in workers’ compensation medicine.

IME's

An Independent Medical Exam (IME) is a medical evaluation by a non-treating physician that documents the worker's condition. IMEs provide medical documentation regarding the injured worker's recovery status, alternate treatment and impairment ratings. OMCA nurses will review the patients' medical history, set up the IME appointment, notify the patient and forward all medical records to the IME physician. The nurse will also follow-up with the IME provider to obtain a timely detailed report.

Medical Fee Audit

Bills are audited by the OMCA medical audit staff to determine if the service is reasonably related to a work-related injury/illness and whether it conforms to usual coding procedures and the state fee schedule (or other agreement with the provider). Necessary corrections are made to the billings and letters of explanation are generated. Verification of the provider's status as an approved system provider is noted (if within a managed care system) and the bill is forwarded to the insurance carrier / third party administrator for processing and payment.

Injured Worker

OMCA staff works with the injured worker to obtain prompt, effective medical care for treatment of the work injury. The Nurse Case Manager is a resource for the worker to obtain information regarding their injury, prescribed medications and proposed treatment. The Nurse Case Manager helps the worker successfully navigate the medical system to return to their pre-injury state of health.

Employer

The OMCA system assists the employer in reporting claims promptly, obtaining information regarding the work status of injured worker and identifying work duties that could allow the employee to return to work within medical restrictions. Those employers who enroll in the OMCA managed care system are assisted in selecting the network of medical providers from which the employee may choose, thereby reducing the opportunity for malingering by those few workers who may attempt to work the system.

Provider

OMCA works closely with the medical provider to get the employee the appropriate care at the appropriate level without delay. Unless there is an issue with compensability of the claim or relatedness of the procedure most pre-certs are approved with the initial phone call. Providers within the OMCA network have access to a provider relations representative who can assist them with questions related to claims filing and reimbursement questions.