Utilization Services
Carlisle & Associates is a nationally-based utilization review company. We focus on assisting our clients in managing the medical aspects of their claims, while ensuring injured workers are provided with timely and appropriate medical care. Overutilization of medical treatment is a major factor in the overall cost of a workers’ compensation claim. We can help reduce costs and treatment outcomes through the use of licensed nurses, board-certified physicians and pharmacists, and the application of data driven evidence-based guidelines. Our professionals cover an extensive list of medical specialties and sub-specialties, serving all fifty states. Carlisle & Associates unique offering of utilization services will provide you with the tools you need.
Case Management Prescription Reviews
This service provides a comprehensive clinical review regarding an injured worker’s medications completed by a licensed pharmacist. This review has been greatly effective in reducing prescription drug costs and can be very valuable when completing Medicare Set-Asides.
Click to learn more about Carlisle & Associates’ Case Management Prescription Review.
Pre-Certification/Pre-Authorization
Pre-Certification is a proactive tool that can be used in the medical management of a workers’ compensation claim. This review provides an evidence-based opinion of medical necessity for a proposed treatment. This is based on submitted medical documentation and evidence-based treatment guidelines such as Official Disability Guidelines (ODG).
Drug Utilization Review (DUR)
A Drug Utilization Review (DUR) involves a more comprehensive review of an injured worker’s medication and treatment to determine medical necessity. A DUR can be completed before treatment begins or retrospectively. In addition, a DUR is extremely valuable in identifying drugs that fall into the same therapeutic class, dangerous drug interactions, and drugs that carry the potential for addiction and overdose.
Issues commonly addressed by a Drug Utilization Review (DUR):
- Medical necessity and clinical indication of medications
- Recommended frequency and duration of medications
- Recommendation for tapering or weaning off medications
- Recommendation on equivalent substitutions/generic medications that may be more cost-effective
- Therapeutic alternatives
Physician Peer Review
A Physician Peer Review is an evidence-based review performed by an appropriately licensed medical professional. This service is used to determine medical necessity of a proposed treatment, or a treatment that has already been provided.
Physician Peer Reviews address:
- Utilization
- Medical Necessity
- Pharmaceutical
- Disability
These reviews can address the following questions on a claim:
- Does the documentation suggest the current symptoms and physical findings are possibly related to the work injury? If not, what specifically is not work-related and why?
- Does the medical treatment follow evidence-based treatment guidelines?
- When was treatment no longer reasonable and necessary to treat the work injury?
- Is the claimant capable of returning to work?
Medical Cost Projections
Medical Cost Projections are designed to help project the future medical costs likely to be necessary based on the history of the illness/injury, treatment to date, diagnosis, and standard of care for the diagnosis. Our MCP’s are produced by a team of accredited medical professionals whose experience enables them to deliver accurate recommendations for the future medical expense. Our team will also provide evidence based cost-saving advisements for the future medical management of the claim.
Life Care Planning
Life Care Planning is an organized, concise plan for current and future needs, with associated costs for individuals who have experienced catastrophic injury or have chronic healthcare needs.
Carlisle Medical account executives can tailor a specific program based on individual company needs. Contact us at 800-960-1118 to speak with a representative concerning how we can begin Making a Difference® for you.
