Products

Our peer review service focuses on the best quality of peer reviews available, matching our peer physician reviewers with the specialty of the claimant’s treating physician or providing a specialized physician that the adjuster may need for legal expertise. We address such issues as compensability, medical necessity, treatment recommendations, diagnostic imaging evaluation, impairment/MMI issues, relatedness, and telephonic contact to better address the adjuster’s concerns. Along with our exceptional customer service delivery, Professional Associates carefully manages a file from start to finish which is coupled with a quick and accurate turn around of the file.

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Our peer review service focuses on the best quality of peer reviews available, matching our peer physician reviewers with the specialty of the claimant’s treating physician or providing a specialized physician that the adjuster may need for legal expertise. We address such issues as compensability, medical necessity, treatment recommendations, diagnostic imaging evaluation, impairment/MMI issues, relatedness, and telephonic contact to better address the adjuster’s concerns. Along with our exceptional customer service delivery, Professional Associates carefully manages a file from start to finish which is coupled with a quick and accurate turn around of the file.

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Performed by a peer physician of like specialty, the Impairment Rating Review provides an evaluation of an impairment and/or MMI date assigned by a physician or Designated Doctor. All of our reviewers are ADL II physicians with experience in performing impairment ratings and determining MMI in their own clinics.

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Performed by a peer physician of like specialty, the Impairment Rating Review provides an evaluation of an impairment and/or MMI date assigned by a physician or Designated Doctor. All of our reviewers are ADL II physicians with experience in performing impairment ratings and determining MMI in their own clinics.

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Performed by a peer physician of like specialty, the Impairment Rating Review provides an evaluation of an impairment and/or MMI date assigned by a physician or Designated Doctor. All of our reviewers are ADL II physicians with experience in performing impairment ratings and determining MMI in their own clinics.

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Professional Associates coordinates all of the paperwork and correspondence necessary to complete the request. This includes sending request letters to the claimant and his/her attorney, if applicable, submission and monitoring of the DWC Form 22 until its approval, and scheduling of the RME appointment. In addition, we send appointment letters to the claimant and his/her attorney, if applicable, and forward the medical records to the RME doctor in a timely fashion prior to the scheduled examination. We also check the appointment attendance of the claimant and obtain a copy of the report to ensure the adjuster has received it. The RME/IME coordinator also corresponds with the adjuster via email after each and every step of the process to answer any questions or handle any issues that may present themselves along the way so that the progression of the examination is as quick as possible. ^ Back To Top

This service includes submission of a DWC Form 32 and the monitoring of the status of the Form 32 at the field office. In addition, once the examination has been scheduled, we notify the adjuster of the date of evaluation and promptly send the records to the Designated Doctor for the assigned examination. After the examination, we verify attendance of the claimant and obtain a copy of the report to ensure the adjuster receives a copy once it has been completed. The adjuster is e-mailed during the process to assure communication regarding the status and progression of the claim throughout. ^ Back To Top

Due to the changes that have recently taken place in regard to Workers’ Compensation in the State of Texas, Professional Associates has developed this analysis to accompany our peer review to further assist the adjuster in timely claim management. This analysis, based on ICD9 codes provided by the adjuster, lists in an easy to read format the description of the ICD9 code, treatment associated with that diagnosis, best practice return to work guidelines, and integrated disability means duration in days for easy reference by the adjuster. The analysis may also be obtained without a peer review for a minimal charge. ^ Back To Top

Our Nurse Consultant file review services may include informal consultations by telephone or in person to discuss particular aspects of a claim and offer suggestions to consider for managing complex medical issues or to clarify medical information. Formal file reviews are provided to summarize medical issues, identify medical information to request from providers, pose questions for a peer review or an independent examiner, identify potential over-utilization of treatment or unrelated diagnoses and/or treatment, or review extended treatment and disability and suggest strategies to manage medical exposure. Such strategies may include targeted limited case management assignments to a vendor, nurse to nurse communication with an onsite case management nurse, identify a specialty for examination or peer review, identify questions to pose to the treating provider, and round table discussion with adjuster and supervisor and/or manager, etc.

Claim Specific Services: The Nurse Consultant may be utilized for specific tasks such as review of proposed contracts with catastrophic claim management services (Paradigm for example) to confirm that all related potential exposures have been addressed and the contract is realistic and to provide interpretation of medical information as needed.

Internal Quality Improvement: The Nurse Consultant may provide retrospective review of vendor services and billing. Examples include review of random sample of monthly pre-authorizations by vendor, review of case management billing to confirm guidelines have been followed, or other reviews as requested. The Nurse Consultant has eight years of experience with vendor management in Worker’s Compensation in Texas.

Staff Education:This may be formal or informal as requested by the carrier. The Nurse Consultant maintains certification as R.N., C.R.R.N., and C.L.C.P. and regularly attends educational seminars for continuing education through the Case Management Society of America. ^ Back To Top

The Nurse Consultant provides a summary of pertinent medical treatment, requests recommendations from treating providers regarding future care needs, reviews billing and treatment to date and collates the information into a claim tool that is specific to the claim for anticipated future medical costs on an annual and lifetime basis. Potential complications are also identified in detail based on the medical information and diagnoses and treatment. This claim tool facilitates realistic reserve projections for the individual claim. Individuals with catastrophic injuries such as major burns, spinal cord injuries, traumatic brain injuries, amputations, chronic pain syndrome, multiple orthopedic injuries with chronic care needs, and psychiatric illness or multiple co-morbidities may be candidates for this analysis. An analysis of the first year of medical costs after a catastrophic injury may be useful at the time of the injury and this can be followed by an analysis of annual and lifetime costs after the claim has “matured” and more information is available for cost projections. ^ Back To Top

The Life Care Plan is a dynamic document that follows established standards and provides a roadmap to effectively predict future care needs and associated costs. The report is developed in collaboration with the treatment team and the claimant and family using a consistent methodology. Recommendations are proactive, preventive, and intended to maximize the effects of rehabilitation. The Life Care Plan educates all parties about the impact of the disability on the individual. ^ Back To Top