Is CareSentry right for you?

1. How do you know what chiropractic and physical therapy bills are appropriate and what ones are excessive or not medically necessary?

Generally, the dollar amount of chiropractic and physical therapy bills are not large, however, it is the insidious nature of multiple encounters over a period of time that can quickly impact your bottom line. It is also difficult to track the accumulation of bills over time to appropriately evaluate the total impact of the claim. The other problem is in having clinical staff or claims adjusters available to review each bill. Expertise and experience in handling these bills may vary dramatically and there is always the issue of staff turnover and retraining.

The CareSentry system will consistently evaluate every chiropractic and physical therapy bill and will reevaluate all bills every time a new bill is entered into the system, thus accurately asses the overall treatment. Additionally, CareSentry does not go on vacation, quit or have varying opinions.

2. If you could identify all the problematic bills, do you have the time and resources to handle the bills or order a peer review?

In a manual process in is nearly impossible to handle the volume of chiropractic and physical therapy claims that have excessive or not medically necessary services. Ordering a peer review can be cumbersome and time consuming, beginning with completing the vendor’s referral form, formulating what review questions you want asked and then collecting and faxing, shipping or mailing in the medical records.

By utilizing the CareSentry suite of products, making a referral is as easy as clicking your mouse and your referral is automatically sent to a MMS connected peer review vendor. The review questions are automatically formulated and inputted into a peer review report template along with the provider data, claimant data and provider charges to be reviewed.

If you have the medical records you can simply fax them in or as an option MMS or one of our connected peer review vendors will request the medical records directly from the provider. In either case, the records will be converted to an electronic PDF file and attached to the referred case within the web-based system.

3. Would you like to have all your chiropractic and physical therapy bills automatically evaluated for:

• Excessive dates of service up-coding
• Inappropriate service duplicative treatment modalities
• Medical necessity of treatment

….and would you like the option to have problematic bills automatically referred for peer review or receive a detailed line item report outlining what services/charges are appropriate and which ones are inappropriate? Then have the option to negotiate the a settlement of the bill with the provider or refer the case for peer review online without cumbersome paperwork, shipping or mailing?

The CareSentry system gives the client flexibility and options; a dollar amount or percentage of the bills threshold can be set within the system that will automatically forward claims for peer review when the threshold is met. This allows for automation of your chiropractic and physical therapy utilization management process. Or, you may whish to receive the CareSentry line item report automatically via fax or email and attempt to negotiate a settlement of the bill without peer review. If bill settlement is unsuccessful, ordering a peer review is just a click away.

As an added feature, by going to our secure web-site you can log in, look up the case and open the CareSentry report. The live form has an expanded pop-up feature for the pend descriptions of the line items identified as excessive, duplicative or not medically necessary. An expanded description of the service, the rationale as to why the system flagged the service and lists any relevant medical literature references supporting the rationale. This provides your staff with the pertinent information and confidence to negotiate a settlement with the provider.

As an optional service, MMS will attempt to settle the provider bill based on the CareSentry report. The provider will be sent a settlement offer letter, a release form and the CareSentry report outlining the charges question. If accepted, the bill is settled for just the cost of the CareSentry report and the release form means the provider is unable to come back at a later date to dispute the payment. You get the results of a peer review without the cost.

The settlement offer is based on the charges determined to be appropriate, plus a percentage of the charges flagged. The percentage is usually from 20 to 40 percent of the flagged charges and is determined by the client.

If the provider does not settle, the case is referred for peer review; however, the total cost is usually about the same or in some cases less than what you are currently paying for peer review alone.

Another option is for the client to generate their own settlement letter and manage the process themselves; your choice.

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