Medata Products, such as, PreView, CareView and DxMedicus can further achieve significant control over excessive treatment and increase savings.
PreView is a web-enabled pre-authorization module which allows users to establish and maintain pre-authorization records. Once entered, the record is electronically transferred to the CORE Bill Review Engine. When the provider’s bill arrives, only those services which have been pre-authorized will be paid. Better yet, since this process is now completely paperless, the pre- authorization workflow becomes seamless, virtually eliminating the possibility of records getting lost in the shuffle.
CareView is a web-enabled, user-friendly application that allows for the entry of provider treatment plans. Within the CareView application are a series of filters, each designed to evaluate medical treatment and the impact of the treatment on a specific claim. One of the filters, Rarity, measures procedures against the claimant’s diagnosis for treatment rendered historically for other claimants with the same diagnosis. For example, if the treatment being requested occurs only once in every 10,000 patients with the same diagnosis, then the provider should be asked to qualify the medical necessity for the proposed treatment in the face of that treatment’s rarity in treating other patients with the same condition. Further, all of the published treatment protocols are available for a similar type of comparison. For example, the “Correct Coding Initiative” (CCI), “Official Disability Guidelines” (ODG), etc., are used to evaluate proposed treatments.
This has several hundred treatment filters available, over and above the CCI and ODG guidelines, to evaluate treatment plans. The evaluation is made, using artificial intelligence almost without human intervention. The response of the system is nearly instantaneous with notification to the provider regarding the treatment plan. In almost all instances, CareView will submit an email to the provider within ten seconds, either authorizing care or raising questions that require information from the provider that would allow authorization. In other words, CareView is designed to either authorize the procedure or obtain information from the provider that would satisfy the medical necessity of the procedures being performed for the condition being treated. If the provider is unable to provide the necessary additional information, no authorization can be granted for performing the procedure. Only pre-authorized CareView procedures would receive payment. Any of the many filters currently available can either be turned on or off, based upon the client’s specifications. Additionally, the seven hundred filters associated with Medata’s CORE system can also be turned on or off when asked for information from the CareView module.
This module is a part of several products within the Medata Development Suite. It prompts either the adjuster or the provider to answer questions directed towards validating the diagnosis for which the treatment is directed. Approximately 1,600 ICD-9 diagnostic codes are responsible for 99.99% of all conditions being treated in workers’ compensation. An artificial intelligence expert system, which consists of algorithms, validates each of the diagnoses. For example, the diagnosis of Strain or Sprain of the Lumbar region (847.2) cannot be made in patients that do not have pain in the low back, and one of the following:
Tenderness to palpation
Limitation of range of motion in the lumbosacral spine
Swelling
In other words, if the patient lacks pain and any one of the above three, then the diagnosis of 847.2 is not valid. DxMedicus is a component of both Toolbox and CareView