Medical Management

Anthem Blue Cross offers medical management programs for workers’ compensation injuries which includes Total Case Management and Utilization Review. We work closely with our clients to provide the specific services that provide quality medical care for the best outcomes possible as well as managing appropriate medical costs.

Our staff works exclusively on workers’ compensation cases and understands the importance of early and proper medical care to achieve an appropriate return to work. The foundation of our medical management services is based on our ability to negotiate with the provider to achieve appropriate medical outcomes. We are California Labor Code compliant and have received URAC accreditation. Our Registered Nurses hold unrestricted licenses in the State of California with an average of eleven years experience in case management and disability management.

Total Case Management

The Anthem Blue Cross Workers’ Compensation Managed Care Services Department offers Total Case Management services that add value to our clients. Working with our clients, we develop a specific program of services tailored to their needs including:

1. Traditional Case Management: The nurse follows the case from the time of referral until the injured worker is returned to full duty or is declared Permanent and Stationary.
   
2. Focused Intervention: The nurse follows the case for a specified period of time and if the recovery is on track, the nurse gives a summary to the adjuster, makes recommendations, provides treatment goals and expectations, and transfers the medical care back to the adjuster. At any time, if the case falls off track, the adjuster refers the case back to Anthem Blue Cross for episodic case management.
   
3. Episodic Case Management: The client requests a one time intervention - i.e., hospital admission, discharge coordination, working with family, assessing injured worker’s needs and assisting with appointments, arranging transportation, etc. When the episode is completed, the case is closed.

Utilization Review

Anthem Blue Cross offers a full Utilization Review program that meets the requirements of the California Labor Code. Utilization Review is offered as either a stand-alone product or as an integral part of our case management services.

Our nurses are supported by I.H.Q., of McKesson, a nationally recognized case management program.

Utilization Review services include:

Pre-certification of surgery
Medical appropriateness of the procedure
Level of care (inpatient vs outpatient and lower levels of care)
Channeling to network providers
Assistant Surgeon
Inpatient length of stay (pre-certification and concurrent review)
Discharge Coordination
Diagnostic studies Epidural injections/nerve blocks
Pain management
Physical therapy
Chiropractic treatment
Acupuncture
Prospective negotiation with non network providers for outpatient procedures
DME

Medical Director

Anthem Blue Cross has a full time Medical Director dedicated to workers’ compensation. Theodore Blatt, M.D., is a board certified Orthopedic Surgeon and a Fellow of the American Academy of Orthopedic Surgery as well as a Qualified Medical Examiner.

Physician Advisor Program

Anthem Blue Cross maintains a 45 member Physician Advisor panel representing 22 different specialties. With our broad spectrum of specialties, we provide ‘peer to peer review’ for provider appeals. If an Orthopedist, Chiropractor, or any other specialty appeals a denial they talk directly with another specialist in their field to resolve the appeal.

Physician Advisor qualifications:

Unrestricted license in the State of California
Board Certification
QME certification for all Orthopedists, Chiropractors, and Neurologists
Minimum of 5 years practice experience
Current active clinical practice

Medical Management results and savings

Workers’ Compensation Managed Care Services tracks collectively and for each client several parameters of the medical management program.