Network Solutions
CorVel offers a complete medical savings solution for all in-network and out-of-network
medical bills including PPO management, specialty networks, medical bill repricing,
true line item review, expert fee negotiations, professional nurse review, automated
adjudication and electronic reimbursement. Each feature focuses on increasing
processing efficiencies and maximizing savings opportunities.
Bill Review
Many states have adopted fee schedules, which regulate the maximum allowable
fees payable under workers’ compensation, for procedures performed by
a variety of health treatment providers. Developed in 1989, CorVel’s proprietary
bill review and claims management technology automates the review process to
provide customers with a faster turnaround time, more efficient bill review
and a higher total savings. CorVel’s artificial intelligence engine includes
over sixty million individual rules, which creates a comprehensive review process
that is more efficient than traditional manual bill review processes.
Payors are able to review and approve bills online as well as access savings
reports through an online portal, CareMC. The process is paperless, through
scanning and electronic data interface (“EDI”), while proving to
be cost effective and efficient. CorVel’s solutions are fully customizable
and can be tailored to meet unique payor requirements.
Bill Review Services include:
• Coding review and re-bundling
• Reasonable and customary review
• Fee schedule analysis
• Out-of-network bill review
• Pharmacy review
• PPO management
• Repricing
PPO Management
PPOs are groups of hospitals, physicians and other healthcare providers that
offer services at pre-negotiated rates to employee groups. The Company believes
that PPO networks offer the employer an additional means of managing healthcare
costs by reducing the per-unit price of medical services provided to employees.
CorVel began offering a proprietary national PPO network in 1992 and today it
is comprised of over 750,000 board-certified providers. The Company provides
the convenience of a PPO Provider look-up mobile application for use with iPhone,
iPad and Android. The application is available to the public and makes it convenient
to locate a provider in the CorVel network. Users can search providers based
on quality, range of services and location.
CorVel has a long-term strategy of network development, providing comprehensive
networks to our customers and customization of networks to meet the specific
needs of our customers. The Company believes that the combination of its national
PPO strength and presence and the local PPO developers’ commitment and
community involvement enables CorVel to build, support and strengthen its PPO
in size, quality, depth of discount, and commitment to service.
The Company has a team of national, regional and local personnel supporting
the CorVel network. This team of PPO developers are responsible for local recruitment,
contract negotiations, credentialing and re-credentialing of providers, and
working with customers to develop customer specific provider networks. Each
bill review operation has provider relations support staff to address provider
grievances and other billing issues.
Providers are selected from criteria based on quality, range of services, price
and location. Each provider is thoroughly evaluated and credentialed, then re-credentialed
every three years. Through this extensive evaluation process, we are able to
provide significant hospital, physician and ancillary medical savings, while
maintaining high quality care. Provider network services include a national
network for all medical coverages, board-certified physicians, provider credentialing,
patient channeling, online PPO look-up, printable directories and driving directions,
and Managed Care Organizations (MCO).
CERiSSM
CERiS, CorVel’s enhanced bill review program, allows claim payors to adjust
individual line item charges on all bills to reasonable and customary levels
while removing all error and billing discrepancies with professional review.
The enhanced bill review program scrutinizes each hospital line description
and charge as a separate and distinct claim for reimbursement. CorVel’s
proprietary Universal Chargemaster defines each code and description, enabling
its registered nurses to identify errors, duplicate charges, re-bundle exploded
charges, correct quantity discrepancies and remove unused supplies.
Professional Review
CorVel’s services offer a complete audit and validation of facility bill
accuracy. This solution also includes review of in-network facility bills. The
Company’s experienced nurse auditors have clinical backgrounds in all
areas of medicine, medical billing and coding to ensure an accurate, consistent
and thorough review. If a bill is identified for professional review, the bill
image and its associated medical reports are routed within the system to an
experienced medical nurse for review and auditing.
Provider Reimbursement
One of the interfaces of CorVel’s bill review service is the automated
issuance of provider reimbursements. CorVel’s provider reimbursement service
allows the ability to determine dollars spent and bills reviewed and to assist
in setting reserves through charts available online. Through the bill review
system, CorVel has the capability to provide check writing or provider reimbursement
services for its customers. The provider payment check can be added to the bill
analysis to produce one combined document.
Pharmacy Services
CorVel provides patients with a full-feature pharmacy program that offers formulary
management, discounted prescriptions, drug interaction monitoring, utilization
management and eligibility confirmation. Our pharmacy network of nationally
recognized pharmacies provides savings off the retail price of prescriptions
associated with a workers’ compensation claim. The Company’s pharmacy
services program includes preferred access to a national pharmacy network, streamlined
processing for pharmacies at point of sale, first fill and next fill programs,
mail order and 90-day retail options, out-of-network management, medication
review services and clinical modeling.
Directed Care Services
CorVel offers a national directed care network that provides access to specialty
medical services which may be required to support an injured worker’s
medical treatment plan. CorVel has contracted with medical imaging, physical
therapy, diagnostics and ancillary service networks to offer convenient access,
timely appointments and preferred rates for these services. The Company manages
the entire coordination of care from appointment scheduling through reimbursement,
working to achieve timely recovery and increased savings. The Company has directed
care networks for CT and bone scans, diagnostic imaging, physical and occupational
therapy, independent medical evaluations, durable medical equipment and transportation
and translation.
Medicare Solutions
The Company offers solutions to help manage the requirements mandated by the
Centers for Medicare and Medicaid Services (CMS). Services include Medicare
Set Asides and Agent Reporting Services to help employers comply with new CMS
reporting legislation. As an assigned agent, CorVel can provide services for
Responsible Reporting Entities (RRE) such as insurers and employers. As an experienced
information-processing provider, CorVel is able to electronically submit files
to the CMS in compliance with timelines and reporting requirements.
Clearinghouse Services
CorVel’s proprietary medical review software and claims management technology
interfaces with multiple clearinghouses. The Company’s clearinghouse services
provide for medical review, conversion of electronic forms to appropriate payment
formats, seamless submittal of bills for payments and rules engines used to
help ensure jurisdictional compliance.
Patient Management
CorVel offers a unique approach to claims administration and patient management.
This integrated service model controls claims by advocating medical management
at the onset of the injury to decrease administrative costs and to shorten the
length of the disability. This automated solution offers a personalized treatment
program for each injured worker, using precise treatment protocols to meet the
changing needs of patients on a frequent basis. The Company offers these services
on a stand-alone basis or as an integrated component of its medical cost containment
services.
Claims Management
CorVel has been a third party administrator (“TPA”) offering claims
management services since January 2007. The Company serves customers in the
self-insured or commercially-insured markets. Incidents and injuries are reported
through a variety of intake methods that include a 24/7 nurse triage call center,
website, mobile applications, toll-free call centers and traditional methods
of paper and fax reporting. They are immediately processed by CorVel’s
proprietary rules engine, which provides alerts and recommendations throughout
the life of a claim. This technology instantly assigns an expert claims professional,
while simultaneously determining if a claim requires any immediate attention
for triage.
Through this service, the Company serves clients in the self-insured or commercially-insured
market through alternative loss funding methods, and provides them with a complete
range of services, including claims administration, case management, and medical
bill review. In addition to the field investigation and evaluation of claims,
the Company also may provide initial loss reporting services for claims, loss
mitigation services such as medical bill review and vocational rehabilitation,
administration of trust funds established to pay claims and risk management
information services.
Some of the features of claims management services include: automated first
notice of loss, three-point contact within 24 hours, prompt claims investigations,
detailed diary notes for each step of the claim, graphical dashboards and claim
history scorecards, and litigation management and expert testimony.
Case Management
CorVel’s case management and utilization review services address all aspects
of disability management and recovery including utilization review (pre-certification,
concurrent review and discharge planning), early intervention, telephonic, field
and catastrophic case management as well as vocational rehabilitation.
The medical management components of CorVel’s program focus on medical
intervention, management and appropriateness. In these cases, the Company’s
case managers confer with the attending physician, other providers, the patient
and the patient’s family to identify the appropriate rehabilitative treatment
and most cost-effective healthcare alternatives. The program is designed to
offer the injured party prompt access to appropriate medical providers who will
provide quality cost-effective medical care. Case managers may coordinate the
services or care required and may arrange for special pricing of the required
services.
The Telephonic Case Manager (TCM) continues to impact the direction of the case,
focusing on early return to work, maximum medical improvement (MMI) and appropriate
duration of disability. Facilitation of appropriate treatment, assertive negotiation
with medical providers and directing the care of the injured worker continues
to be the Case Manager’s role until the closure criteria is met. Utilization
review of provider treatment remains ongoing until discharge from treatment.
In the event that a claim may require an onsite referral, a Field Case Manager
(FCM) will be assigned to the claim. Cases can be referred to CorVel based on
geographic location and injury type to the most appropriate FCM. Specialized
case management services include catastrophic management, life care planning,
and vocational rehabilitation services. All FCMs have iPads that provide access
to the Company’s proprietary mobile applications that provide instant
access to detailed case information and the ability to enter case notes. An
additional feature of our iPad applications is the ability to electronically
approve and email signed case management forms and documentation.
24/7 Nurse Triage
Injured workers can call at the time of injury or incident and speak with a
registered nurse who specializes in occupational injuries. An assessment is
immediately made to recommend self-care, or referral for further medical care
if needed. CorVel is able to provide quick and accurate care intervention, often
preventing a minor injury from becoming an expensive claim. The 24/7 nurse triage
services provide channeling to a preferred network of providers, allows employer
access to online case information, comprehensive incident gathering, and healthcare
advocacy for injured workers.
Utilization Management
Utilization Management programs review proposed care to determine appropriateness,
frequency, duration and setting. These programs utilize experienced registered
nurses, proprietary medical treatment protocols and systems technology to avoid
unnecessary treatments and associated costs. Processes in Utilization Management
include: injury review, diagnosis and treatment planning; contacting and negotiating
provider treatment requirements; certifying appropriateness of treatment parameters,
and responding to provider requests for additional treatment. Utilization management
services include: prospective review, retrospective review, concurrent review,
professional nurse review, second opinion, peer review, precertifications and
independent medical evaluation.
Vocational Rehabilitation
CorVel’s Vocational Rehabilitation program is designed for injured workers
needing assistance returning to work or retaining employment. This comprehensive
suite of services helps employees who are unable to perform previous work functions
and who face the possibility of joining the open labor market to seek re-employment.
These services are available unbundled, on an integrated basis as dictated by
the requirement of each case and client preference, or by individual statutory
requirements. Vocational rehabilitation services include ergonomic assessments,
rehabilitation plans, transferable skills analysis, labor market services, job
seeking skills, resumé development, job analysis and development, job
placement, career counseling and expert testimony.
Life Care Planning
Life Care Planning is used to project long-term future needs, services and related
costs associated with a catastrophic injury. CorVel’s Life Care Plans
summarize extensive amounts of medical data and compile it into a comprehensive
report for future care requirements, aiding improved outcomes and timely resolution
of claims. The Life Care Plans also provide working guidelines and points of
reference for the family of a disabled person. Some of the features of the Company’s
Life Care Planning services include: comprehensive documentation, projecting
future care requirements, customized reporting, certified documentation and
costs specific to local areas.
Disability Management
CorVel’s disability management programs offer a continuum of services
for short and long-term disability coverages that advocate an employee’s
early return to work. Disability management services include absence reporting,
disability evaluations, national preferred provider organizations, independent
medical examinations, utilization review, medical case management, return to
work coordination and integrated reporting.
Liability Claims Management
CorVel also offers liability claims management services that can be sold as
a stand-alone service or part of patient management. The Company’s services
include auto liability, general liability, product liability, personal injury,
professional liability and property damage, accidents and weather-related damage.
This service includes claims management, adjusting services, litigation management,
claims subrogation, and investigations.
Auto Claims Management
Injury claims are one of the largest components of auto indemnity costs. Effective
management of these claims and their associated costs, combined with an optimal
healthcare management program, helps CorVel’s customers reduce claim costs.
The Company’s auto claims services include national preferred provider
organizations, medical bill review, first and third party bill review, first
notice of loss, demand packet reviews and reporting and analytics.