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MCN brings efficiencies to medical bill review processing, with leading solutions for workers’ compensation and auto injury medical bill review.
MCN provides complete outsourcing through our Cost Management Service Bureau, offering solutions to fit each client’s need. With extensive EDI and scanning capabilities, MCN can provide a user-customizable workflow. We take client defined claims handling rules and automate the process through the use of decision management software. Our clients inform us of the dramatic improvement in claims management productivity, resulting in bill review accuracy and consistency. The powerful decision engines use an extensive database of state fee schedules and the industry’s largest number of automated, national (and regional) PPO contracts to help you obtain the maximum savings on every bill. MCN can assist your claims manager’s workload by increasing workflow automation, getting the right bills to the right resources every time.
In the implementation process, MCN can conduct a study of physician payment history to aid in the selection of the most appropriate preferred provider by jurisdiction down to the zip code level. We make sure that the right provider is selected for the right state.
Do you have customers that require Telephonic Case Management triage when a claim meets certain criteria? What about Utilization Review parameters? Our Decision Management program provides rules that trigger at key points in the claim process, helping you automate the identification of actions that need to be taken throughout the claim. Our rules building team, works in conjunction with your experience and criteria to assure that needs for these services are consistently identified and captured. We can automate actions that you choose in your own claims management process. Bill review customers who use our system find it an excellent vehicle for increasing efficiency and ultimately reducing the costs of conducting business
MCN has developed this program in response to today’s need to go beyond Preferred Provider discounts and bill reductions. We are on the leading edge with our approach and look forward to working with you in implementing it on your claims
Table of Contents Decision Management MCN’s Decision Management Solution provides the over-arching workflow, database management and audit tracking capabilities to simultaneously orchestrate any number of unique decision-making processes for enforcement of client directed rules, these could include the following:
Treatment protocols
Treatment benchmarking
Utilization review parameters
Case management enforcement/criteria setting
SIU Protocols – link with databases
PBM protocols and linkage
Network development protocols By attaching this decision management tool to your medical bill review services, MCN is able to link the enforcement of its client’s claims management protocols to the overall financial management of the claim. The ensuing results in taking this step toward further automation are staggering. Claims managers can handle more claims more efficiently with underlying improved results for both the claimant and the carrier.
State Fee SchedulesMCN provides enforcement of all state and federal fee schedules through its bill review services. We maintain current data for workers’ compensation, auto fee schedules and federal Medicaid and Medicare programs. This allows us to efficiently review all state and federal programs, including OWCP and Jones Act
Usual and customary reviewDRG ReviewDiagnostic related groups (DRG) are a system of categorizing patients based on the primary and secondary diagnoses, primary and secondary procedures, age, and length of stay. These categories establish a uniform cost for each category and set a maximum amount that should be paid for a given category of care. MCN takes hospital bills in jurisdictions where DRG bill review is appropriate to objectively evaluate the level of a given bill. The resulting bill savings can be dramatic.
Hospital Bill AuditsThrough Chargemaster, HCPCS, DRG and other tools, MCN compares hospital charges with Medicare reimbursement and price and cost data for hospital outpatient services in the cost-based statistical area to identify potential additional savings. MCN looks at CPT® and HCPCS Level II codes that may be missing and identify additional savings within each clinical department segment. We look at client data by hospital utilization statistics to identify line items that have the biggest impact on reimbursement. MCN has trained and experience specialists in this area to help you review your hospital bills.
Pharmacy Networks and ReviewPharmacy costs make up between 10% and 15% of the total workers' compensation and auto medical bill. Our pharmacy benefit manager partners (PBMs) bring cost containment to the pharmacy portion of the total medical costs realized by workers' compensation and auto insurers while providing an enhanced level of care to the injured patient. MCN integrates this service with its medical bill review to assure that the appropriate payments are made on the pharmacy portion of the bill. Upon notification of an accepted claim, our pharmacy partners send the injured patient his or her personal Pharmacy Card. This card identifies the individual patient as an approved claimant and provides the pharmacist with the information needed to process the prescription online.
The PBM Pharmacy Card contains all the information the pharmacist needs to provide members with their pharmacy benefits. It also carries the PBM’s name, and the number of their toll free help desk. Possession of a PBM Pharmacy Card assures your injured claimant that he or she will be well cared for as part of MCN’s family of services. And presentation of the card at any network pharmacy notifies the pharmacist of the appropriate pharmacy care that is required for your injured claimant.
PPO Management and MaintenanceMCN delivers one of the most sophisticated PPO management tools to its medical bill review clients. Based on our client’s geographic needs MCN can configure an unlimited number of PPO networks down to a specific zip code. We take client claims data and analyze which group of networks has the deepest penetration and discounts in a given location. Using this data MCN can come up with a layered approach, giving our clients the maximum coverage and savings in a given region. Let MCN analyze your claims data to determine your company’s maximum savings configuration. Below are some of MCN’s PPO partners.
• Aetna / Network Login
• Blue Cross Blue Shield / Network Login www.aetna.com
• First Health / Network Login
• Focus / Network Login
• Three Rivers / Network Login
• Scriptnet / Network Login www.sciptnet.com
Inpatient and Outpatient Line Item ReviewAn area of unrealized potential for greater savings is the review and re-pricing of complex provider billings for new and innovative services and equipment, hospital services and surgical procedures. Successful review and re-pricing of such lengthy and confusing bills can be draining on time and resources, and can be inadequate in the absence of the best information and training.
MCN provides the information and training needed. MCN’s medical bill review analysts and on-staff medical professionals include physicians, registered nurses and consultants who are skilled at identifying billed charges that may warrant review and revision. We review each bill to determine appropriateness of treatment and ensure provider compliance with fee-schedule guidelines.
When necessary, we assist in determining medical necessity through research of new and innovative medical services and equipment. As needed, we obtain peer review consultation with practicing physicians and provide expert testimony to support findings.
Negotiated Discount When substantial charges are identified where there is no preferred provider contract to assist in the reduction of medical charges, MCN’s bill review team contacts the provider in question to negotiate a reasonable charge for the medical procedure in question. MCN captures this information with the provider so that when future bills similar to the bill in question occur a reduction can be obtained.
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