Auto Injury Management

The care they deserve. The savings you expect.

    Auto accidents can be painful for all parties involved. From the serious physical trauma policyholders endure, to the complexity of the claim for the claims handler that can come with complex claims – everyone deserves quality service and peace of mind.
    FirstMCO’s Auto Injury Management program is dedicated to providing quality care and attention to policyholders while ensuring claims handlers and insurers are updated on the latest advancements with the claim. Policyholders get the proper care to help them get back to a normal life and claims handlers can rest easy knowing that along with the outcomes-focused treatment comes cost effective management.

NJ Pre-Cert

Our staff of medical professionals prospectively determine the optimal level of care for policyholders and the medical necessity of proposed treatment plans. First MCO’s comprehensive pre-certification process ensures provided services are compliant with treatment guidelines by using industry-leading prior authorization, utilization review and case management protocols. We diligently adhere to the New Jersey Automobile Insurance Cost Reduction Act of 1998 (AICRA) to ensure benefits to injured parties are given the appropriate level of care.

Pre-certification

Since the enactment of the New Jersey Automobile Cost Reduction Act of 1998, First MCO has provided Decision Point Review (DPR) and Pre-certification services on behalf of the insurance industry. First MCO has an approved plan on file with the New Jersey Department of Banking and Insurance.

First MCO’s professional staff will implement your plan for Pre-certification or Decision Point Review. If your organization requires assistance with approval or developing your plan, our experienced staff is available to assist with your filing.

The First MCO Advantage 

  • Pre-certification / DPR services can be a stand-alone review or incorporated as part of a comprehensive utilization review / case management program
  • Eliminates inappropriate or unrelated medical treatment
  • Reports from our board certified medical professionals provide rationale for determinations that will “hold up” in legal review
  • Compliance with New Jersey Statutes
  • Experienced Registered Nurse Case Managers
  • Web Based System available for client access using integrated Technology
  • Arbitration Support Available by Legal Nurse Consultant

Medical Director Reviews (MDR)

If a treating provider proposes care that is outside the guidelines of the New Jersey Care Path’s or beyond the scope of nursing, our board certified physicians are utilized to review the claim for medical necessity and appropriateness.First MCO’s Medical Directors are practitioner’s board certified in their specialty. When indicated, our physicians may verbally consult with the treating provider or collaborate on the best course of treatment for the eligible injured party. A report is provided, with rationale, documenting the outcome of the determination.

The First MCO Advantage

  • Reports supporting determinations that stand up to legal review
  • Board Certified Practitioners of all specialties, with like specialty review, as mandated by NJDOBI
  • Board Certified reviews completed within the mandated 72 hour time frame
  • Physicians available for telephonic or onsite testimony

Life Care Plans

Definition: “A dynamic document based upon published standards of practice, comprehensive assessment, data analysis and research, which provides an organized, concise plan for current and future needs, with associated costs, for individuals who have experienced catastrophic injury or have chronic care needs.”

First MCO will provide our customers with a complete life care plan including accident history, present treatment, future treatment, medications and a breakdown of medical costs.

Our life care planners play an important role applying expert knowledge of the psychosocial, medical, and economic aspects of disabilities and chronic health care conditions.

Bill Audit Services

First MCO provides onsite and desk audit services performed by our staff of experienced Registered Nurses. Our audit specialists ensure appropriateness of provider billing practices assuring that bills are repriced in accordance with the Usual and Customary or PIP Fee Schedules.

The First MCO Bill Review Advantage

If PPO access option is chosen by our customer, the provider contracts stipulate that all disputes must go through First MCO’s Internal Dispute Resolution System for settlement

  • Web-based voluntary provider network tool lookup
  • Automated bill review
  • Our system can accommodate electronic billing
  • Identification of unrelated medical conditions/pre-existing conditions
  • Negotiation of prompt pay discount
  • ICD-9/CPT code review

Case Management

Case management may be evaluated from four perspectives: consumer satisfaction, process, outcome and cost effectiveness. The combination of these four methods has yielded First MCO’s case management extremely successful.The goal of our Case Management team is to assist and monitor quality medical care to injured persons while minimizing costs. Our team consists of licensed nurses who are well trained in medical rehabilitation and have extensive experience in auto injury management. Sometimes, auto claims require more than just medical treatment. Our Case Managers work closely with the inured party and insurance adjuster from the onset of injury until maximum health is achieved. They will assess, plan, facilitate, monitor and evaluate options and services for the best possible medical treatment while containing costs.

The First MCO Advantage:

  • Proactive experienced RN’s certified in case management (CCM)
  • Additional auto claims management products available to incorporate a comprehensive package rather than outsourcing individual services (IME, Audit, Bill Review & Negotiation)
  • First MCO will customize a program to meet our customers’ needs
  • With adjuster authority, ability to utilize the network providers for further discounts
  • Real time access to electronic files

Case Management Services offered:

  • Contact by experienced RN within 24 hours to claimant, medical provider, adjuster and attorney (if applicable).
  • Compliance with New Jersey Division of Banking and Insurance and the Auto Insurance Cost Reduction Act (AICRA) mandates utilizing the NJ Care paths, Decision Point Reviews and Pre-certification standards
  • Board Certified Medical Directors and Independent Examiners of every specialty and licensure.
  • Nursing and clerical assistance with preparation of material to support and defend determinations made by First MCO should a claim be filed for arbitration

UR Services

First MCO coordinates multi-line Independent Medical Evaluations, Peer Review, and Diagnostic Evaluations. Our Independent Medical Evaluations provide fair and objective examinations of the individual and clinical records. Our experienced staff reviews the claim referred and selects the proper physicians within our network to evaluate the medical condition and address claim concerns. We will assist in determining appropriateness of care, whether maximum medical improvement has been achieved, and any other issues requested in the referral.

Independent Medical Exams

First MCO is committed to providing our customers with a clear and concise report with a final opinion that they can act on. We maintain a diverse panel of board certified physicians who all actively practice in their specialties. You can be confident that your report will substantiate your position in the event of litigation. Credentials for physicians in our IME network are available for client review.

The First MCO IME Advantage:

  • Board Certified Physicians in private practice
  • Thorough Evaluations
  • Timely and Influential Reports
  • Reliable and Valid Documentation
  • Fast Fax Report within 24 hours of claimants examination
  • Dedicated Account Representative

Functional Capacity Review

A Functional Capacity Evaluation (FCE) is defined as an intensive short-term evaluation that focuses on major physical tolerance abilities related to the musculoskeletal strength, endurance, speed and flexibility.

The following are situations that are appropriate for a FCE referral:

  • Clients who have met a plateau in progress made by all interventions
  • Clients who may need maximum medical improvement rating
  • Determination of disability
  • Assessing if a client may return to work
  • Assistance determining a client’s consistency of effort or presence of symptom magnification

Peer Reviews

First MCO’s knowledge of practice guidelines, national standards and process improvement, enables us to provide customers with a comprehensive peer review evaluating all aspects of the clinical care provided to a patient.

Our physicians use evidence based medicine and guidelines in a number of categories, which may include: medical necessity, standards of care, over / under utilization, length of stay, and pharmacy.

The First MCO Advantage:

  • Unbiased third-party reviewer
  • Physician’s board certified in private practice
  • Timely Review
  • Prompt and Efficient Reviews
  • Physicians in all key medical specialties

Act IV Peer Review (PRO)

First MCO is a Certified Peer Review Organization (PRO) under Act IV, within the Commonwealth of Pennsylvania. As such, our peer review product meets strict quality and time restriction standards.

An Act IV Peer Review (PRO) conducted by First MCO includes: 

  • The collection of all appropriate medical documentation for review.
  • A thorough, objective analysis of medical records by a board certified specialist
  • License and specialty to determine the appropriateness of treatment.
  • Determination of medical necessity, goal – oriented treatment, causality issues, and appropriate documentation of patient response to treatment program.
  • Rationale for opinions based on accepted standards of medical practice.
  • A complete report with concise recommendations for denial or future management of treatment.
  • Report reviewed by a Nurse to assure quality and clarity.
  • Time frame: Maximum 90 days; Average 45 days.

Bill Review / Audit

The bill review program you choose can have a significant impact on how much your organization spends and saves. Our customized and comprehensive approach to bill review has a proven performance record of outstanding results united with excellent customer service. We place special emphasis on extensive discounts partnered with quality assurance that results in an unparalleled level of cost savings.

PIP Fee Scheduling and Bill Review Services

First MCO provides medical bill review services using a web-based system integrated with our utilization management database. This integration assures proper bill re-pricing based on pre-certification history. By utilizing First MCO’s pre-contracted and negotiated auto specific medical provider network, we are able to achieve savings nearly 15 % below the PIP FEE Schedule.

Medical Bill Review Includes:

  • Application of State Fee Schedules or Usual & Customary Fees
  • Application of PPO Network
  • Anesthesia and Surgical Review
  • CPT Code Review
  • Application of NCCI edits when appropriate
  • Duplicate submission check
  • Generation of EOR
  • Validation of Pre-Certification requirements
  • Response to provider inquiries
  • Diagnosis code review for causality
  • Support for arbitration and litigation
  • Electronic data submission and sending
  • Negotiation services when no fee schedule/UCR applicable
  • Nurse Review of appropriateness of services

Bill Negotiations

In order to realize maximum savings, First MCO has developed a non-network negotiation program to work in conjunction with our network savings. Non-network bills are channeled to the negotiation team for efficient and effective processing, providing a total management solution.

Bill Audit Services

First MCO provides onsite and desk audit services performed by our staff of experienced Registered Nurses. Our audit specialists ensure appropriateness of provider billing practices assuring that bills are repriced in accordance with the Usual and Customary or PIP Fee Schedules.

The First MCO Bill Review Advantage

If PPO access option is chosen by our customer, the provider contracts stipulate that all disputes must go through First MCO’s Internal Dispute Resolution System for settlement

  • Web-based voluntary provider network tool lookup
  • Automated bill review
  • Our system can accommodate electronic billing
  • Identification of unrelated medical conditions/pre-existing conditions
  • Negotiation of prompt pay discount
  • ICD-9/CPT code review
  • Ensure appropriate care

  • Optimize recovery speed

  • Contain unrelated costs

  • Improve overall satisfaction

Submit a Referral:

24/7 Toll-Free: 1-800-831-9531

Intakedepartment@firstmco.com

© Copyright 2018 | FMCO | All Rights Reserved