Manages medical aspects of claims in conjunction with ensuring injured workers are provided with timely and appropriate medical care. Over-utilization of medical treatment is a driving factor in the overall cost of a Workers’ Compensation claim. SFUR, through the use of licensed nurses, board certified physicians and application of data driven evidence-based guidelines, addresses costs through a proactive approach.
Independent Medical Exams (IME)
Independent Medical Exams are examinations of an injured worker by a doctor that that has not been previously involved in the claim. An opinion is provided based on review of the medical documentation and a physical examination of the patient. The doctor addresses questions as posed by the requesting party.
Early Compensability Review
A process where the claims adjudicator determines if there is evidence of an injury and, if so, the extent of the injury as supported by the medical documentation. The benefit of an assessment of compensability in the early stages of the claim as well as an anticipated medical treatment plan is to avoid unnecessary medical expenses.
Drug Utilization Review
A process to assist the adjuster in addressing claim pharmaceutical usage. These reviews are conducted by a licensed pharmacist who addresses the appropriateness of an injured workers drug regime. This review offers medical evidence to support the use of medications or the lack of evidence to support the continued use of mediation, and can provide a recommended drug detoxification program when appropriate.
Physician Peer Review
An evidence-based review performed by an appropriately licensed medical professional to determine medical necessity of a proposed treatment or treatment that has already been provided.
A review of medical necessity performed after the service has been provided. As with pre-certification, this review provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.
Pre Certification/Pre Authorization
A proactive process that can be used in the medical management of a workers’ compensation claim. This review type provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.