How It Works
Our Nurse Care Review program adds medical guidance to the claims process. Ensuring mid-range cases do not become “runaway” cases, our nurse reviews typically trigger on cases over 30-60 days of disability. These reviews provide a thorough assessment of medical treatment for injuries that don’t quite meet a payer’s catastrophic protocols, but do have the potential to be extremely costly if not managed properly – injuries such as complicated fractures, knee, hip, back and multiple trauma.
In determining if appropriate treatment is being rendered, outcomes from Rising’s nurse reviews could range from: recommending a Physician File Review, to a Pharmacy Review / Negotiation for weaning a patient from certain medications, to logging the case for follow-up in 30 days.
Why? Wage replacement used to be the largest portion of workers’ compensation claims, so payers did not require as much medical guidance to manage claims effectively. Now, the largest portion of workers’ compensation claims is medical, weighing in at about 70% of the total expense. That’s why, today, payers require more medical guidance to make appropriate treatment decisions and cut excessive costs.
Payers also rely more heavily on technology to make claims decisions than they used to; but in certain cases, it’s not enough. Human expertise, in addition to technology, plays a crucial role in reining in medical costs that could spiral out of control.
Our ideal mix of technology and the human hand enable Rising clients to make evidence-based medical decisions. Additionally, our flexible access options allow clients to trigger nurse reviews automatically or on a referral basis, empowering them to use the program how they want, when they want.