Medical management

Medical management

Having the right people and programs in place can help ensure that your injured workers receive quality medical care while also effectively managing medically related costs.

Why Zurich?

Zurich’s integrated medical management service takes advantage of on-staff dedicated specialists, nurses and physician advisers, as well as a robust network of providers working together to provide technical experience and high-quality customer service.

Our proactive and responsive approach is designed to help

  • Locate high-quality medical providers for injured workers
  • Ensure appropriate and accurate treatment and billing
  • Deliver targeted intervention and mitigation strategies
  • Promote return-to-work goals

Case management

By using their medical knowledge to address health and wellness issues and offering encouragement and guidance to the injured employee, nurse case managers can help lay the groundwork for the earliest possible return to work.

Zurich nurses help oversee the care of injured workers through:

  • 24/7 catastrophic injury response
  • Coordination of home care, pharmacy, equipment and/or outpatient services
  • Early intervention
  • Telephone and/or on-site case management
  • Vocational case management

Medical bill review

Zurich delivers a consistent and rigorous bill review service to help our customers control the total cost of a loss.

All medical bills are sent through a rules-based system, which performs the following:

  • Prices bills based upon fee schedules, fair and reasonable allowances and state guidelines
  • Interfaces with PPOs to help ensure timely and accurate contractual cost reductions
  • Confirms services are in line with the reported workers’ compensation diagnosis
  • Identifies duplicate submissions to help avoid duplicate payments

Complex bills are further reviewed by medical professionals to evaluate:

  • Treatment relative to workers’ compensation injury
  • Fairness of billed services
  • Discrepancies between billed charges and services documented

Narcotic evalution

Zurich’s Narcotic Evaluation is a component of the Pharmacy Management program and is designed to address the growing concerns with narcotic use.

Claims submitted for review are assigned to a nurse case manager who reviews the file to identify potential mitigation opportunities. Each case reported to the program receives a case closure report showing the outcome and potential benefits of the referral.  

There are three components to the program:

  • Targeted letters (all narcotics) - Selected parameters with regard to narcotic utilization will trigger targeted letters to the medical provider(s) addressing the identified concerns and requesting specific responses.
  • Benefits manager referral (Class II narcotics) - When the narcotic utilization escalates to hit identified triggers set forth by the narcotics program, Zurich’s pharmacy benefit manager will identify claimants for further review.
  • Claim professional referral - Since each claimant may have different needs and circumstances surrounding their narcotic medication usage, Zurich claim professionals can also identify and refer claims to the program that originally did not meet the automatic referral criteria.

For cases requiring additional knowledge, a physician adviser may also be engaged.

Pharmacy management

Zurich’s Pharmacy Management program helps deliver quick and convenient prescription fulfillment at no out of pocket cost to injured employees and at a cost savings to employers.

Benefits include:

  • Complete first fill program
  • Prescription ID cards can be used at more than 70,000 pharmacies
  • Optional home delivery and online prescription processing
  • Advanced technology tracks prescription needs
  • Narcotics evaluation for workers compensation claims

PPO networks

Zurich networks leverage more than 1 million credentialed providers to offer high-quality, accessible service at negotiated rates for your injured workers’ medical, pharmacy and specialty needs.

The consistent use of a PPO has many benefits, but most notably the following:

  • Credentialed providers help ensure a high-quality service network
  • Negotiated rates, possibly below fee schedule and/or reasonable and customary rates
  • Medical providers understand return-to-work goals

To locate a provider, Zurich customers can use our C.a.r.e® Directory Online.

Utilization review

URAC seal

Utilization review can help injured employees receive the appropriate medical care, allowing them to recover more quickly from their injury.

Zurich’s medical utilization review program is accredited by the American Accreditation HealthCare Commission/URAC, a nationally recognized standard that demonstrates a commitment to quality healthcare.

Review services may include:

  • Pre-certification
  • Concurrent Review
  • Pre-admission certification
  • Continued stay management
  • Retrospective reviews

For cases requiring additional expertise, a physician adviser may also be engaged.

Zurich Care Plus

Zurich Care Plus is a program that uses innovative technology to predict and monitor an injured worker’s anticipated course of treatment. Coupled with timely and targeted medical professional intervention, Zurich Care Plus can help maximize medical improvement for injured workers and improve claim outcomes.

Three key program elements:

  1. Care plans: Customized care plans, leveraging evidenced-based treatment guidelines and key medical information, are delivered to claim professionals on average within 24 hours of filing a workers’ compensation claim.
  2. Bill review: As injured workers receive care and bills are submitted to Zurich, each charge is reviewed relative to the care plan to help ensure medical necessity and relatedness of treatment. Charges that fall outside of the care plan are flagged for nurse review.
  3. Nurses: Zurich’s team of nurses plays a key role and can help:
  • Evaluate medical necessity for recommended treatment that deviates from care plan
  • Advise on mitigation strategies when injured workers do not progress as expected
  • Optimize care plans to account for each worker’s unique circumstances and comorbid conditions