Litigation Resolution Plans

The regulatory landscape in workers’ compensation is always changing and evolving.  Managing those changes and ensuring that each is in compliance can be a challenging task. As a result, PRIUM as established a Regulatory and Consulting Team, made up of experienced medical management specialists to help navigate this challenging environment.  They are attorneys by trade and possess a unique skill set necessary to provide direction for clients facing one of the most difficult challenges in our industry today: chronic pain.

By outlining a strategy and obtaining buy in from defense counsel and the claims administrator at the outset, all parties are able to be in sync with the plan the most optimal plan for claim resolution. PRIUM’s team is available to assist throughout this entire process and help ensure that the time, effort, and cost that is being put into managed care tools is being effectively managed and deployed.

 

Litigation Support Analysis

PRIUM’s team will work with claims administrators, clinical personnel and defense counsel to ensure that available managed care tools are being effectively deployed and utilized in the litigation process.

For each identified claim, PRIUM will:

  • Review all the medical records, utilization reviews, independent medical examinations, judicial orders, and related documents to evaluate the quality and timeliness of the tools that have been deployed.
  • Prepare a detailed report that will summarize our findings and provide a roadmap of what options should be used for the best potential outcomes.
  • Discuss the strategy with the claims administrator and defense counsel to make adjustments and ultimately secure agreement to proceed.

For claims that proceed to a hearing or judicial intervention PRIUM will:

  • Prepare a trial binder containing all managed care tools employed to date.
  • Work with defense counsel to ensure full understanding of how to best position each document, how to enter them into the record, and how to leverage the body of evidence that will be presented.

 

Deposition Support

In many cases, hearings are won or lost based on the quality of the deposition given by the payer’s third party physician. These physicians, whether testifying about a utilization review determination, independent medical examination, or peer review are essential in cases where overutilization of medical treatment is at issue. PRIUM’s team will work with defense counsel to assist in the deposition process to ensure that the appropriate questions are asked, evidence is properly referenced, and objections are properly raised. PRIUM’s team will also work with the physician to prepare them for the deposition and the types of questions that they will be asked. The team will utilize internal clinical resources where appropriate, including physicians to ensure our client and defense counsel are fully prepared for the deposition and in the best position to gain positive outcomes. 

 

Regulatory Compliance

PRIUM’s team can work with clients to inform them of ongoing regulatory changes that may affect their claim population and assist in the implementation of those changes. From minor language changes to complex drug formulary implementations, PRIUM’s team can provide guidance and perspective on how other payers are complying and the steps that need to be taken. PRIUM’s team works closely with the regulators in many jurisdictions which give us perspective and insight on how to best comply with new regulations.