Why Is Achieving Maximum Medical Recovery (MMR) Critical?
The effect of not achieving the maximum medical recovery in relation to any personal injury case is one of claims cost, which can increase substantially as a result of poor MMR results. This usually occurs when the claimant’s recovery from injury is less than satisfactory and the patient did not recover to the full extent of their pre-accident condition. This results in what physicians commonly refer to in their medical reports as “sequelae” indicating that the patient was left with some degree of disability or limited functionality as a result of the patient’s injury.
Radiology & Diagnostic Services (RD/038)
HCB through our affiliated network providers can deliver cost effective radiology and diagnostic services. These institutions provide the most advanced diagnostic and imaging services available anywhere in the world.
Independent Medical Examination (IE/019)
HealthCare Barbados can coordinate and schedule an IME (Independent Medical Examination) with one of our consulting physicians according to the specifics required or medical terms of reference. HCB will make all the arrangements including appointment scheduling and coordinating transportation if required. Written communication would be forwarded to both the patient and physician securing a confirmation by both parties. A report will be generated providing the requested information and the file will be closed unless the insurer requests further activity.
Determining Medical Necessity of Treatment (DT/013)
Before the implementation of any care program we work with all parties including the claimant and the insurer to confirm the entitlement of the claimant to the care being prescribed or requested. Consultations are held with the claimant to assist in explaining, planning and coordinating their rehabilitation and recovery from their injuries.
Identification of Medical Provider (ID/018)
The first step involves identifying the appropriate care provider; through our network of affiliates, we then recommend or appoint the most suitable physician or facility, and schedule an appointment to facilitate an initial consultation. Arrangements can also be made in the event of a medical emergency within 24 hours of receiving a request.
Pre-admission certification (PA/034)
All requests for pre-admission certification review is referred to our Medical Panel to determine medical necessity, utilizing clinical criteria specific to the condition or service under review. Notification regarding certification or non-certification is then promptly communicated to the party or parties of interest.
Once all of the necessary protocols have been met, including pre-certification, any hospitalization required as it relates to inpatient care with accompanying surgery, or outpatient surgery, the designated case manager will work with the claimant to coordinate all hospital and preliminary requirements. After admission to hospital, a case manager monitors the claimant’s stay in hospital to ensure the earliest possible discharge is achieved. In complex or difficult cases, a case manager may work with the doctor to develop a treatment plan that substitutes less expensive care whenever possible.
Coordination of inpatient admissions and determination of length of stay (CIA/009)
If hospitalization is required our case manager will coordinate all matters relating to inpatient admissions, providing interim reports regarding the length of stay as well as follow-up reports informing insurers of the patient’s discharge from the centre of care. HCB will make the necessary arrangements whether locally or at an international institution. However HCB does not decide when it is safe for the patient to leave the hospital. The HCB case manager working with the attending physician coordinates the best recommendation in matters relating to care and discharge, as provided within the medical orders issued by the physician and services provided by the insurer. Once discharged, the HCB case manager can arrange for medical equipment, nursing and other healthcare services to be administered in the patient’s home where medically necessary.
Constant Monitoring Of Patient
Our case managers will provide constant updated and timely reports on the ongoing treatment and recovery progress of the claimant, and any developments which may require the decision-making authority of the insurer to participate in. At no time therefore is the company “sprung” any surprises, since HCB operates at all time as an extension of the company.
Discharge Planning (DP/014)
Discharge and rehabilitative planning begins with an assessment of the claimant’s current and future care needs, then, taking into consideration the claimant’s resources, a discharge plan is developed, with full input from all parties, including the claimant’s family and insurers. Because these arrangements can be time-consuming, discharge planning begins early in the claimant’s hospitalisation. The emphasis here is to get the claimant rehabilitated and back into a productive and earning lifestyle capacity as quickly as possible.
Medical Second Opinions (MS/024)
Second opinions have been standard medical practice for years. Based on the simple concept that two heads are better than one, seeking a second opinion is a prudent choice not only for the patient but for insurers as well. As much as we would like to hope not, there are several cases of misdiagnosis that cost payers significantly each year. To the patient a second opinion may mean the difference between life and death; and to the organization paying the bill it may result in significant savings off medical and other expenses. Getting a second opinion allows you not only to confirm the diagnosis but also to get a different perspective on treatment options.
Healthcare Barbados will collect information on your client’s needs, assemble medical records, and identify hospitals that have the expertise needed to address your case. Upon receipt of a Second Opinion, if follow up diagnostics or treatment is required, HCB will help to identify hospitals best suited to provide care. If necessary, we will assist in scheduling admission and provide other logistical support. This service is not limited to local treatment alone, HCB has partnered with various international medical centers, which allows for the delivery of medical assistance on a worldwide basis.
Emergency Medical Evacuation (EM/016)
If an insured is involved in an accident or suffers a sudden illness and adequate medical facilities are not available locally, HCB can undertake medically supervised evacuation to the nearest “center of medical excellence” capable of providing the required care, or any facility you request. During such a medical emergency, access to quality treatment is an immediate concern. HCB will, through our Network Provider services, promptly and efficiently coordinate evacuation to a facility equipped to handle the illness or injury.
Our medical assistance personnel supported by our medical panel will make all arrangements for the swift and safe transfer of the patient, including ground transportation to the receiving facility. Once at the receiving hospital, HCB will continue to monitor the patient’s treatment and communicate with physicians and family members if Case Management services are required. These services are not restricted to Barbados alone; we can extend to the wider Caribbean area or worldwide through our associated service providers.
Utilization Management Procedures (UM/043)
Our UM program is designed to provide clinical review of the medical necessity, while ensuring the delivery of, high quality, cost-efficient health care. This service can include the following:
Post Trauma Psychological Assessment (PT/037)
Hospital care has the fundamental intention of saving life, but what about the emotional wounds brought about by severe injury? It is generally accepted that early professional intervention after a major incident can serve to reduce the complex mental reactions after injury, and can hasten the individual’s functional recovery, i.e. return to work/school. At HCB we recognize the need for integrating the objectives of the surgical team with the psychological care where necessary, especially in cases where trauma has occurred. Our intention is to reduce the incidence of Chronic Post Traumatic Stress Disorder, and other psychological problems that affect recovery and loss of productivity. Our aim is to assist in a more efficient utilization of health care services and reduce the patient’s “down-time” by getting them back into the workforce as effectively and as quickly as possible
Ancillary Medical Services (OS/032)
Through our network of affiliated service providers, we can provide the following essential services:
Investigation of Pre-Existing Conditions (PE/035)
It is not unheard of for a claimant to seize upon an opportunity following a new occurrence, to claim against an insurer for an injury which previously existed. Where insurers require the investigation or confirmation of a pre-existing condition, we possess within our network the pre-requisite skills and medical expertise to facilitate such a request. We guarantee that such an investigation will be conducted in an environment of professionalism with the highest regard for ethical standards and confidentiality.
Medical Laboratory services (OS/032)
HCB can arrange for the collection and transfer of laboratory specimens in accordance with accepted and established international protocols, and the results will be returned to the point of request directly from the Lab using established means and observing the maximum security and confidentiality.
Travel and Accommodation & Concierge (TAC/042)
Our total care program is geared to relieving the claimant of many of the concerns that can prevent them from achieving maximum physical recovery. Where off-island care is required we can assist in securing ground and air ambulance services (if required), and transportation at the point of destination. We can also arrange for transfers between airport and medical facility or place of accommodation.
Air & Ground Ambulance (AA/001 & GA/017)
When an emergency airlift is required we are available 24 hours a day for our clients; HCB can assist in making critical decisions in respect of emergency evacuation if we are involved from the initial stages. We can arrange emergency air transportation to an affiliated care centre or to any other facility of the insurer’s choice.
Claims Adjudication (CD/006)
HCB facilitates the adjudication, settlement or resolution of the claimant’s medical bills. The process involves reviewing and evaluating billings submitted from providers. This is done in order to protect from over-billing and to ensure that costs are reasonable. This requires some knowledge of the UC&R (Usual, Customary and Reasonable) charges for the service and the bundling of billing methods used by doctors and hospitals.
Billing review and cost containment services where applicable (BRC/004)
We offer an accounting and audit verification service on bills received for payment. Bills are thoroughly examined for errors, over-billing, and submission of non covered cost factors for settlement.
Cost recovery and coordination of benefits (CRC/012)
When preliminary investigations reveal or indicate the existence of another responsible party, we will work at assisting with the recovery of contribution payments where required from these other parties. Our cost recovery services are available in areas involving payments made in error, cases requiring subrogation, contribution or in pursuit of co-payments, we can bring our legal and accounting affiliated associates expertise to bear in such cases.
Co-Insurance Subrogation & Third-Party Recovery
Recovery of medical claims cost can be complex and sometimes difficult to administer. Identifying responsible parties and negotiating recovery of costs for claims paid will be a priority once we have established that that is your interest. HCB will investigate and assist in pursuing subrogation rights against other liable parties.
Through HCB’s medical review and referral system, injured parties will have access to only the best medical practitioners and support staff. Our medical advisory panel is committed to excellence in medical care management and recommends only highly credentialed medical personnel for its referral services. This coupled with our utilization review guarantees the best outcomes possible for the client.
HCB is constantly building quality relationships within our network of providers, as well as with a number of international cost-containment service providers who have developed sound reputation for fairness and integrity in fee negotiation efforts. Through these affiliations we are able to assist our clients in realizing savings by negotiating reduced fees for hospital and physician charges on a case-by-case basis.
Medical Bill Audits Review of a file and/or bill to render an opinion on such issues as appropriateness of treatment to claimant’s diagnosis or accident and subsequent related costs.
Utilization Review Encompasses review of inpatient and outpatient procedures and treatments; and may involve reviews by physicians, not associated with HealthCare Barbados.
Peer Review HealthCare Barbados can arrange to have a specialized physician review medical records and diagnostic studies to determine appropriateness of care or proposed plan of treatment. A full report will follow the evaluation.
Life Care Planning We will review the current status and history of the referred patient and will research to determine the approximate lifetime costs of medical care. This information is extremely useful in setting reserves for catastrophic cases.
Rehabilitation (RS/040) HCB will work with and monitor the progress of the referred injured party, ensuring compliance with the prescribed physiotherapy or occupational therapy programs recommended by our medical consultant.
Technology Driven Claims Management
At HealthCare Barbados we use specialized medical management software programs similar to that employed by hospitals and clinics. The technology (see screen shots A & B below), provides our case managers with the tools necessary to efficiently monitor a claimant’s care and rehabilitation. The system is designed to flag any inconsistencies as they relate to the claimant’s injury complaints and the agreed treatment program. Access to medical information including diagnostic results and medical reports are readily facilitated due to ICD 9 coding classifications, which allow for the timely preparation and submission of updates and reports to insurers, including the interpretation of medical terminology contained in medical report for ease of reference.
At HealthCare Barbados the use of technology features prominently at all stages of our case management intervention with the patient. All medical and non-medical consultations are electronically documented and form part of the patient’s records and subsequent report. Starting with a non-medical fact-finding consultation to obtain the relevant information surrounding the patient’s medical condition, to a signed case management release on completion of the rehabilitation program, signifying that the medical care provided was satisfactory and according to the physician’s prescribed treatment plan.
The claimant’s file is continually updated after each consultation with the relevant information, including all diagnostic results, prescriptions, recommendations and any equipment purchased. This allows for the continued monitoring of the claimant’s progress and the associated cost incurred. We also provide our clients with a secure website login portal, which allow them special access to reports.