Solutions Center

A dedicated problem-solving unit that provides guidance on a client’s most complex and costly cases.

ExamWorks Clinical Solutions (ECS) offers an integrated medical and pharmaceutical solution targeted at complex claims. By combining clinical and pharmaceutical specialists expertise, we deliver an outcome-based value proposition. In conjunction with our national case management and MSP compliance solutions, we effectively manage your most complex medical claims.

RX Analysis

Our RxAnalysis evaluates medical records and payment histories to identify potential areas of concern. The RxAnalysis team's PharmD professionals are committed to reducing medication costs and to improving claimant functionality. By providing new medication recommendations, as information is obtained during a Physician Outreach, our PharmDs outline changes to the medications with identified savings.

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ECS PharmDs deliver an outcome-based value proposition by reviewing and analyzing the injured worker’s prescription history, researching drug interactions, dosages, synergies and contra indications, assessing alternatives and/or conducting Physician Outreach. PharmDs address potential signs of fraud, waste and abuse, and offer solutions that result in savings to our customers.

Physician Outreach

Our Physician Outreach service is performed in conjunction with our RxAnalysis services. Clients receive recommendations from an ECS PharmD after contact is made with the physician or provider to discuss recommendations. The PharmD provides documentation outlining:

  • Recommended pharmacy changes
  • Results of the conversation with the treating provider
  • Savings when the physician agrees to recommended changes

Signed confirmation of the conversation is obtained from the provider following the outreach. Additional services can be provided to monitor the file and ensure the agreed-upon changes have been implemented.

Peer Review

Our Peer Review Service is a thorough examination of medical reports by a licensed, credentialed and active practice physician who addresses questions regarding treatment and medications. Once the Peer Review is completed, the physician will contact the treating/prescribing physician to facilitate the medical treatment changes or recommendations outlined in the Peer Review report.

Medical Director
Consultation

ECS' medical director may provide technical expertise relating to:

  • Medical management of hospitalized patients, discharge planning and complex case management
  • Clinical aspects of the pharmacy and medical management program
  • Peer-to-Peer consultation
  • Cost reduction in treatment or pharmaceutical protocols

Medical Advisory Panel
Consultation

Our Medical Advisory Panel (MAP) is a team of leading medical providers, pharmacists, nurse practitioners and allied professionals with advanced certifications and specialized training. Relying on the collective knowledgebase of integrated service offerings, the panel works directly with treating providers, pharmacy experts and the claims team to achieve the best possible outcomes. The MAP is also available for consultations when there are specific medical questions and complex claims that need clarification.

Nurse-To-Doc
Negotiations

ECS professionals conduct a respectful discussion with the physician to better understand the medical rationale for clients seeking assistance with changes in anticipated pharmacy and treatment costs within a Medicare Set-Aside (MSA) or a complex claim. Case Managers provide recommendations about pharmaceutical and treatment information to the attending physician based on the injured worker’s medication profile and comparable case reviews compared to nationally recognized standards.The outcome aspires to a safer lifelong medical plan that results in lower overall costs.

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When direct face-to-face contact with the attending physician is required, ECS will provide case management support to facilitate a personal meeting. The ECS Case Manager will receive the assignment to follow up with the attending physician to secure documented treatment plan or medication changes. Written agreement by the attending physician will be obtained and provided.

MSA Resolution Services

ECS' MSA Resolution Services analyze MSAs and accompanying Addendums for issues which could prevent a case settlement.  Our Resolution Services team focuses on obtaining documentation, correspondence and records which could present challenges during the Centers for Medicare & Medicaid Services' (CMS) submission process, if not obtained and clarified prior to the submission process.  The service produces a reliable MSA allocation, accurately identifying cases not suitable for filing with CMS, thereby reducing the overall cost to carrier clients and the time associated with the CMS submission process. ECS' MSA Resolution Services can resolve Development Letters upon issuance from CMS after submission to obtain the requested items.