Managed Care

Comprehensive Managed Care

Focused on recovery and return to work

With medical and pharmacy costs nearing 60 percent of workers’ compensation claims expenses, you need a risk management partner that has the expertise, capabilities, and programs to effectively manage these costs while helping you return employees to work as soon as is medically appropriate. PMA’s Managed Care programs are driven by our integrated, in-house team that is highly credentialed and 100 percent focused on workers’ compensation. 

PMA’s Managed Care Philosophy

With a holistic and strategic approach to Managed Care, PMA continually seeks to address the care needs of injured workers while optimizing programs to reduce the medical and pharmacy spend. Above all, we strive to support a prompt and safe return to work, which leads to the best outcomes for clients and injured workers. 

PMA’s Managed Care Programs

PMA has integrated all of our Managed Care programs to maximize every opportunity to support appropriate, quality care while addressing escalating medical and pharmacy costs. Our Managed Care program can also be strategically linked to PMA claims services, optimizing results and increasing client satisfaction. Our Managed Care programs include:

Medical Bill Review Program

As more injured workers require increasingly complex and expensive interventions—such as surgery and medication—our team conducts in-depth reviews with a dual focus on ensuring that providers are billing for the appropriate treatments and that employers are paying appropriate fees for that care. PMA’s medical bill reviewers include certified medical coding specialists and registered nurses. Our program includes:

• Fee schedule and usual, customary and reasonable (UCR) reviews
• Complex bill review, including detailed review of all inpatient and outpatient hospital bills
• Medical bill review quality assurance spanning the entire medical bill review process
• Duplicate bill review to ensure the same bills are never paid twice

PMA Medical Network Strategy

As part of PMA’s commitment to providing appropriate and quality care to injured workers, we provide access to extensive networks of multidisciplinary providers that specialize in workers’ compensation, as well as diagnostic imaging centers and other ancillary service providers. Our program provides:

• Access to the largest national provider network in the workers’ compensation industry
• Specialty networks, including physical therapy, durable medical equipment and  diagnostic imaging centers
• Negotiation programs for providers that do not participate in our preferred network
• Creation of provider panels

Pharmacy Benefits Management (PBM) Program

In recent years, pharmacy utilization and costs have skyrocketed. PMA’s comprehensive PBM program includes oversight and active management of drugs—particularly narcotics—to help ensure that injured workers are receiving appropriate intervention at an appropriate cost to their employers. In addition, our PBM program includes:

• Retail and mail order pharmacy
• Generic conversion
• Clinical management and formularies
• Medication review program, peer-to-peer review
• Independent medical examination
• Drug testing and monitoring program
• Out-of-network program
• Injured worker narcotics education
• Fraud, waste, and abuse detection unit

Pharmacy Nurse Early Intervention Program 

PMA provides a team of registered nurses who are trained to effectively manage complex files utilizing pharmacy resources and tools that best support the needs of the individual injured workers.

• Application of clinical guidelines assist in establishing appropriate treatment regimens that inhibit possible long-term medication dependency
• Pharmacist and physician resources to drive alternatives in pharmacy regimen
• Educational materials provided to injured workers on the dangers of narcotics abuse
• Monitor and reinforce proper medication usage to increase safety and effectiveness

PMA Medical Management Program 

Early intervention and appropriate treatment can improve outcomes for injured workers and employers alike. PMA’s comprehensive, proactive approach leverages highly experienced registered nurse case managers. With their medical and workers’ compensation knowledge and commitment to patient education, our team works to help injured workers safely recover and return to work when healthy. We also perform ongoing monitoring of injured workers’ care, helping to identify “red flags” before they have a significant impact on medical outcomes and costs. PMA’s Medical Management Program includes:

• Triage Assessment
• Telephonic Case Management
• Field Case Management
• Catastrophic Case Management
• Utilization Review
• Peer-to-Peer Review
• Medical Cost Projection