Auto reviewing provider recruitment

Our unique approach to auto claim management goes beyond simple transactional savings and looks at the claimant’s appropriate treatment. This helps Optum ensure the level and time of care are appropriate, effective, and drive to the best outcome at the lowest possible cost.

We achieve this by partnering with experienced reviewing providers to perform the following services.

Independent Medical Examination

Independent Medical Examination (IME) - An Independent Medical examination (IME) is necessary when a provider, who has not previously been involved in a patient’s care, examines the patient. An IME can address questions relating to a claim such as causality, extent and medical necessity of treatment for an injury or injuries, and address whether the maximum benefit has been reached. 

Paper reviews

• Medical Director Reviews (MDR) - A MDR is necessary when services being reviewed for medical necessity do not meet the initial review criteria, at the Telephonic Case Manager (TCM) level.  The TCM will refer the request to a Medical Director Reviewer.  The Medical Director Reviewer will hold a non-restricted license to practice medicine in the state of New Jersey
• Pre-Service and Post-Service Appeals - If a provider is not in agreement with a medical determination or a bill determination the disputing provider may request an internal appeal.
• Retrospective Peer Reviews - A Peer Review is a review of treatment, diagnostic tests, and other medical services by a provider for assessment and recommendation/determination of medical necessity and reasonableness. Optum will coordinate a Peer Review when a treating provider has performed services that were not submitted for medical review.  

Contracted Reviewing Provider

• Flexible Arrangements – Providers can choose volume
• Wide range of services – Providers can choose which types of reviews (paper and/ or IME)