The faculty is introduced and the goals of the course are explained, i.e. teaching you how to get started in file reviews and do this work at a very high level so that you can earn repeat business. Also included is a discussion of what it takes to succeed as a file reviewer and how this work will make you a better clinician for your patients.
Disability vs. Medical File Review Consulting: Compared, Contrasted, & Explained
Medical file reviews and disability reviews are compared and contrasted with and to IMEs. Different approaches the physician reviewer will take to succeed in each area are provided. Discussion will also cover the clinical review skills applicable to file & disability review work, the nuts and bolts of file & disability review work, and the typical questions medical file review physicians will be assessing.
Medical File Reviews: Evidence-Based Analysis
A discussion of the shift from clinician to evidence and documentation-based analysis that is critical for a physician to be successful at file review work. Discussion will also address the facts, data, and definition restrictions that are typically relevant to performing high level utilization reviews, pre-authorizations, chart reviews, and medical necessity reviews. Sample reviews are analyzed.
Writing Excellent Physician File & Disability Reviews
You will learn a protocol and style physicians can utilize to write high quality file and disability reviews. Included is a discussion of efficiency, conciseness, red flag words to avoid, formatting, attestation, and how to express your opinions properly dealing with the weight of the evidence, collateral evidence, and support with objective facts/data.
Case Studies: Medical File Reviews
Four practice file review case studies that you can complete: an ER visit, cancer treatment, and two surgical authorizations. Each case study is discussed and explained.
How to Succeed as a File Reviewer
An explanation of how file review work is used in the healthcare industry and the life cycle of a UR case is followed by advice on how to efficiently conduct reviews and tips for success in peer to peer calls. Insight on the lifestyle benefits of file review work is provided.
Medical Necessity File Review: Opportunities and How to Succeed
An explanation of the structure of the multi-billion dollar file review industry and the significant opportunities for physicians within this industry. UM process flow and the role of Independent Review Organizations (IROs) are explained. Advice for how to excel at medical necessity reviews and how to meet or exceed client expectations are provided.
Medical Necessity Reviews: A Proven Process To Produce High Quality Reviews, With Examples
The three types of medical necessity reviews are explained (prospective, retrospective, and concurrent). You will learn the techniques for doing reviews at both high quality and high volume. Discussion includes the parts of a high-quality review and using guidelines such as InterQual and MCG. A broad range of example reviews are discussed (inpatient stay, urine drug test, PT, opioid, durable medical equipment, gene testing, and Cologuard DNA analysis).
How to Conduct an Effective Peer to Peer Call
Tips and tricks to conduct effective and productive peer to peer calls with providers. Advice is provided to diffuse potential antagonism, establish collegiality with providers, and properly document your calls and attempted calls. Sample P2P call recordings are analyzed and discussed.
Disability Consulting for Physicians
An introduction to the field of disability consulting including legal issues, the medical and collateral information that is commonly considered, what to look for in the records, how to get better information than the treating physicians, and multiple ways to evaluate functional ability. The fundamental concepts of capacity, risk, tolerance, impairment, limitations, and restrictions are explained and demonstrated. The use of medical and pharmacy records, lab data, surveillance videos, and social media in the file review process is explained.
Disability Contracts: What you need to know
Disability is a legal, not a medical term. In this section you will learn to understand the key terms in disability contracts, including any occupation, own occupation, pre-existing conditions, reasonable and appropriate care, and limitation clauses. The important differences between Group (ERISA) and Individual Policies is explained. Examples are provided.
A review of the potential red flags that physicians doing reviews want to be aware of, their significance, and how to deal with them. Examples include psychosocial issues, pain conditions, doctor shopping, psychiatric conditions, substance abuse, and disciplinary problems.
Medication and Diagnostic Testing
A discussion, with examples, of the role that specific types of medications have on activity restrictions, including dosing, side effects (such as fatigue and drowsiness), and cognitive impairment. Also included is advice on value and limitations of diagnostic testing for disability reviews and an analysis of how the inability to drive (e.g. due to medication side effects) does or does not create disability.
Reasonable and Appropriate Care & FAQs
An explanation of the reasonable and appropriate care requirements and the difference between reasonable and appropriate care vs. regular care. Frequently asked questions regarding disability reviews will be answered.
Disability Opinion Case Reviews
A review and discussion of five complex disability review opinions. Each case includes the diagnosis, questions posed, clinical findings and collateral information, and the answers to the questions posed.
Critiques of Reviews & Avoiding Mistakes
The faculty provide comments on the good and not so good on a variety of sample file reviews including short term disability, long term disability, medical necessity, and veterans' benefits. In addition, a bullet point list of the biggest mistakes file reviewers make is presented and suggestions for avoiding these mistakes are provided.
A practical discussion of how to obtain high quality work, what insurance companies are really looking for, and making yourself desirable will be led by the faculty.
BONUS: The attendees will be provided with the names and contact information for 100 prime referral sources for file review work. Recommendations will be made as to the best way to solicit and obtain this work.
A frank discussion of the potential ethical challenges faced by physician disability and file review consultants including maintaining your credibility and effectiveness, always being able to defend your findings and never having to say you are sorry.
Practice Settings for Physicians
A discussion of the type of file review consulting practices available to physicians (in-house vs. independent) will be presented and the advantages and disadvantages of each will be explained. The faculty discusses how to start and run a file review consulting practice, working as an employee, and how to find and maintain high quality work.