Why is URAC accreditation important?
URAC is an independent, nonprofit organization that is well known as a leader in promoting health care quality through its accreditation, education and measurement programs. OMCA’s URAC accreditation for Workers’ Compensation Utilization Management demonstrates our commitment to quality, accountability and efficiency of health care management.
In Kentucky, what are the benefits of a certified managed care organization?
Our certified MCO is a technique that seamlessly combines, all of OMCA’s value added service programs (Network, UR, Peer Review, Physician Advisory Panel, Pharmaceutical Innovations and Registered Nurse Case Management) to better control your workers’ compensation dollar and help your injured employees get back to worker sooner. In Kentucky, only those employers in a certified managed care organization can direct claimants to a panel of select providers. A network is not the main benefit of an MCO. Maximum benefits of an MCO can only be obtained through appropriate UR/PR and aggressive case management.
Are OMCA services available nationwide?
Yes. Case Management, Utilization Review, Peer Review models, and Network Linkage that we have developed, are available to employees/employers/carriers on a nationwide basis.
How can I better control my ever-increasing post award medical costs?
OMCA’s ClaimsCLEAR® and PharmCLEAR® programs are specifically designed to address large, complex post award cases. Using specialty matched physician intervention, we have been very successful in convincing treating physicians to voluntarily change expensive and inefficient medical care.
In Kentucky, isn’t it unusually difficult for a small to medium sized employer or regional carrier to qualify as a certified MCO?
On the contrary, OMCA has an “off the shelf” MCO product that can be specifically tailored to a geographic area or unique carrier situation. OMCA takes care of all the details from initial application to recertification requirements.
How do excess / reinsurance carriers use OMCA programs to control their case reserves?
Typically, OMCA assists excess/reinsurance carriers in reducing their ultimate case exposures with a three pronged approach:
A) Early identification/intervention when case reserves reach a certain percent of attachment points or key trigger points commence (i.e. multiple surgeries, escalating narcotics, expanding symptoms or diagnoses, pain management).
B) File review, analysis and treatment recommendations before or as soon as attachment points are pierced.
C) Evaluating old/complex post award cases that run through established reserves to better organize and compile medical history, improve current treatment protocols and help bring the file to appropriate medical stability.
OMCA uses their ClaimsCLEAR® and PharmCLEAR® products to help our clients better understand their exposures, and ultimately implement a more effective treatment plan and reduce case reserves.
Why isn’t bigger always better when it comes to a workers’ compensation provider network?
Not every physician is cut out to be a good workers’ compensation provider. In order to be considered for OMCA’s network a provider must be willing to timely communicate to multiple stakeholders, be focused on safe return to work as soon as possible and be willing to make those tough clinical decisions that are ultimately in the best interest of an injured worker.
Once an award is in place, aren’t I on the hook for whatever medical procedure a treating physician orders?
No, but effectively contesting proposed medical fees, procedures or pharmaceuticals must be approached scientifically. Administrative Law Judges want the best and most effective care for injured workers. However, the treating physician’s decisions will typically win out, unless the best documented, independent scientific medical evidence proves otherwise. This is where OMCA excels. Our physician advisors are exceptionally skilled at getting treating physicians to voluntarily change their ineffective protocols or alternately provide such convincing evidence to regulators that even post award cases will be denied inappropriate treatments / procedures.
Aren’t all Pharmacy Benefit Managers the same?
Unfortunately there are both good and bad work comp PBMs. OMCA can help you sort through the complex maze of the pharmaceutical industry and help you find a PBM that is:
A.) Totally transparent in their cost structures;
B.) Has no hidden fees, rebates or add-ons;
C.) Has an effective Formulary;
D.) Competitively priced;
E.) Uses enhanced UR to combat extent, duration, reasonableness, relatedness and off-label usage.
What can be done to address rampant narcotic abuse?
OMCA’s PharmCLEAR® program uses Board Certified Physician specialists to provide evidence that certain pharmaceutical protocols are simply “bad medicine”. These physician specialists have had good success in convincing treating and pain management physicians to change their narcotic prescription protocols by:
A.) Providing scientific literature on inefficiency and destructiveness of long term opioid use;
B.) Documenting danger of “off label” or “non FDA” approved use of certain medications;
C.) Explaining how pain is exacerbated and not relieved from certain prescription regimens;
D.) Providing alternative treatment plans to physicians looking for other answers.
If you need further assistance or clarification on any of these answers, call the Client Services Department at (502)495-5040, or 1-800-KYCOMP-1 (1-800-592-6671)
From our Clients & Colleagues
Yasmine Subhi Ali, MD, MSCI, FACC, FACP Nashville Preventive Cardiology
"Thank you so much for the update and for passing along the feedback! You helped make my day. :-) I have to say, you all at OMCA have been extraordinarily easy to work with, too, and I look forward to continuing to work with you!"
- Utilization Review
- Managed Care Organization
- Pharmaceutical Solutions
- Medical Cost Containment