“Scientific Solutions for Complex Situations”
The ClaimsCLEAR® program targets complex or post-award cases with significant medicals, long-term narcotic use, unending pain management, multiple prescription drugs and complex medical facts. The primary objective of ClaimsCLEAR® is to reduce case reserves by lowering your future medical costs.
ClaimsCLEAR® untangles complex claims by:
- Utilizing the best minds in medical science
- Utilizing the latest scientific-based medical evidence
- Bringing clear medical thinking to your most complex catastrophic claims
OMCA ClaimsCLEAR® Services
Complex Case Review
Phase 1. Nurse reviewers provide a written review of the medical history and current treatment plan.Issues of concern are identified, recommendations are provided to assist in the medical management of the claim. Optional services include referral to a ClaimsCLEAR© physician reviewer, or intensive nurse case management.
Phase 2. Physician experts provide a written review of medical care and treatment recommendations based on national guidelines, such as Official Disability Guide (ODG) or American College of Occupational & Environmental Medicine (ACOEM). The ClaimsCLEAR® physicians will make evidence based recommendations to improve the clinical outcome for the patient while reducing unnecessary costs to the payer.
Peer to Peer Intervention
The best way to modify ineffective treatment plans and ultimately control medical costs is to have the treating physician voluntarily change his/her pattern of treatment. Whether it be prescription drugs, extended pain management or unnecessary surgeries, treating physicians can and do change their minds.
Often it is helpful for our reviewing physician to contact the treating physician directly. These conversations can be very productive and can result in a change in the patients’ treatment protocols. Many treating physicians pay little attention to reviews offered by those outside their specialty (e.g., neurosurgeons pay little attention to RNs, pharmacists, or other physicians). When the reviewer is a peer-to-peer match, however, the result is often positive.
OMCA provides ClaimsCLEAR® services to carriers, third party administrators and self-funded employers. These programs are also effective for excess/reinsurance carriers and prior to the offering of buyouts, MSAs or loss portfolio transfers.
FirstCLEAR® is a scientific, evidence-based medicine program designed to provide early identification of claims, which if left unchecked, will become catastrophic. Virtually all catastrophic claims have points throughout their continuum that present opportunities to dramatically improve the outcome of the case.
The easily understood FirstCLEAR® matrix helps identify those claims. FirstCLEAR® Registered Nurse Case Managers and physician advisors then intervene with adjusters and treating medical providers to maximize the likelihood of improved outcomes and minimize the likelihood of the runaway, catastrophic case.
To learn more about ClaimsCLEAR® and FirstCLEAR®, contact Rosalie Faris, RN, BSN, CCM,COHN-S at firstname.lastname@example.org.
From our Clients & Colleagues
Madonna Senger Workers' Comp Adjuster
“The best network ever was the original PPO network of OMCA.”
- Utilization Review
- Managed Care Organization
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