- FROI Processing
- Treatment Request Review
- Treatment Plan Development
- Medical Management
- Bill Review
- Return-to-Work Planning
- Voc. Rehab. Coordination
- Communication

- Utilization Management
- Case Management
- Maternity Management

Overview of Services

AdvoCare is a group health and workers’ compensation managed care organization.

AdvoCare's Workers' Compensation Managed Care Organization (MCO) provides medical management, bill processing, and dispute resolution services to both state-funded and self-insured employers. AdvoCare works with the injured employee, the employer, and the provider to develop a plan for treatment, review treatment requests, monitor the cost and quality of care, and establish return to work goals - with careful consideration of the needs of each participant. From the first report of an injury through a successful return to work, we strive to provide significant cost containment without sacrificing customer service or optimal patient care.

AdvoCare's Group Health Division provides utilization review, case management, and maternity management services to its clients. Through review of the necessity, appropriateness, and efficiency of services rendered under industry-accepted guidelines, utilization management seeks to ensure that the patient receives the correct level of care required. Select cases are referred to case management based on complexity, severity, and chronicity. Maternity management works with women throughout a pregnancy to provide education, guidance, and identification of high risk factors.

To find out more about how the AdvoCare Advantage can work for your company, click here.

Workers' Compensation Managed Care

AdvoCare is a workers' compensation managed care organization (MCO) in the State of Ohio and is a nationally accredited by URAC as a case management company. Since the formation of the Health Partnership Program (HPP) in 1997, AdvoCare's workers' compensation managed care program has provided a complete array of medical management services. These workers' compensation services are designed to assist your employees in their productive return to work.

Our Workers' Compensation services include:

• FROI Processing
• Treatment Request Review
• Treatment Plan Development
• Medical Management
• Bill Review
• Return-to-Work Planning
• Voc. Rehab. Coordination
• Communication

To learn more about our workers' compensation services, please contact us at:

Group Health

AdvoCare’s Utilization Management program is designed to manage healthcare costs by reviewing medical services for necessity, appropriateness, and efficiency to ensure that a patient receives the right level of care. Our program reduces the number of unnecessary or inappropriate healthcare services by approving admissions and procedures, determining length of stay, and conducting discharge verification. AdvoCare has the ability to customize services required for authorization based on the client’s individual benefit plan.

AdvoCare’s Case Management program utilizes registered nurses who focus on those cases requiring an additional level of management based on complexity, severity, and chronicity. The case managers make the healthcare system work for both the patient and the client by influencing and managing quality, cost, satisfaction, and optimal health status across all healthcare settings. The nurse case manager works in partnership with the patient and their family, the physician, and the claims payer/TPA to facilitate and coordinate appropriate care and services as well as patient-centered approaches to education self care management.

Our Maternity Management Program is an early identification and intervention program that assists mothers and babies in having a healthy start with pregnancies, births, and newborn care.

FROI Processing

First Reports of Injury (FROIs) are processed to ensure timely submission to the Bureau of Workers' Compensation. Upon notification, the BWC assigns a claim number, and treatment can be rendered for the injury.

Treatment Request Review

Requests for treatment of a work-related injury, along with any supporting medical documentation, are reviewed by a nurse. Based on this information, the nurse determines if the treatment is both necessary and appropriate for the allowed conditions on the claim.

Treatment Plan Development

In coordination with the employee and healthcare providers, a nurse case manager will create a care plan that considers all aspects of the employee's recovery and assists with a safe and timely return to work.

Medical Management

Ohio state-funded employers are required to select a managed care organization (MCO) to manage their workers' compensation claims. Every two years, the Ohio Bureau of Workers' Compensation authorizes an "Open Enrollment" period during which each Ohio employer is free to evaluate and change their selection of an MCO to be their medical management company.

The goal of any managed care program is to improve the quality of healthcare for patients while ensuring that treatment reamins cost-effective for the employer. As your managed care provider, AdvoCare will attempt to identify claims requiring extensive care, utilizing a team of expert nurse case managers to ensure that treatment is appropriate for the injury. By utilizing a network of healthcare providers ceritfied by the Ohio BWC, AdvoCare ensures that your employees receive optimal care. Throughout the claim, we will provide medical case management and compensation management to ensure that the quality and the cost of care are being monitored.

To learn more about our MCO services, please contact us at:

Bill Review

Medical bill review is a vital part of cost containment for employers. AdvoCare delivers a comprehensive collection of bill review services to assit employers with work related injuries. At AdvoCare, our team of experts can guide providers in submitting accurate bills for timely payment. AdvoCare's medical bill review services have helped employers experience significant savings from identifying and eliminating inaccurate hospital bill charges.

For more information on our medical bill review services, please contact us at:

Return-to-Work Planning

In conjunction with the injured employee, employer, and physician, goals are established for returning the employee to work safely.

Vocational Rehabilitation Coordination

AdvoCare will identify injured employees who may benefit from additional services provided within a vocational rehabilitation plan. These services include job retention, gradual return to work, and job search assistance.

• These services are not applied to the employer's risk, instead being covered through the surplus fund. This protects the employer's premium rate.
• Certified Rehabilitation Counselors are utilized to attend physician appointments with the injured employee and keep the case on track for a timely return to work.
• Remain-at-work services can be utilized for those injured employees that have difficulty doing their particular job.
  • The number of lost days may be reduced as a result, ultimately lowering the employer's premium.
  • These services are charged to the employer's risk fund, not the surplus fund.

Communication

Throughout the claim, AdvoCare will communicate with and educate the injured worker, employer, and provider regarding the claim process and treatment plan. Ongoing communication is essential for a well coordinated, timely, and safe return to work for the injured employee.

Utilization Management

AdvoCare's utilization management program is designed to manage healthcare costs by prospectively monitoring the use of healthcare services. This program facilitates the appropriate provision of employee health benefits in meeting the patient’s need for care. Utilization management includes medical, surgical, maternity, pediatric, mental health, and chemical dependency review services.

Decisions are based on medical necessity determination utilizing national, industry-accepted guidelines and individual patient clinical information. All treatment decisions remain the responsibility of the patient and the attending physician. Utilization management also provides an opportunity for identifying potential case management referrals for those cases requiring a higher level of management and intervention.

Case Management

AdvoCare uses a comprehensive medical management approach for all case review. AdvoCare’s case management, as a component of overall medical management, focuses on those cases requiring an additional level of management because of complexity, severity, chronicity, or use of medical resources.

AdvoCare's case management aims to:

• assist in assessing and planning for an individual’s need for health services in a timely and cost-effective manner;
• promote quality, safe, and cost-effective care;
• minimize the fragmentation of healthcare services across the continuum of care provider community;
• foster quality, effective, and efficient access to healthcare services;
• assist patients in achieving an optimal level of wellness and function while empowering the patient to make informed decisions;
• facilitate communication and collaboration with all appropriate parties;
• assist with coordinating and implementing treatment plans that are clinically appropriate;
• promote quality cost-effective outcomes; and
• monitor and evaluate outcomes.

Maternity Management

AdvoCare's Maternity Management Program aims to identify women early in their pregnancy in order to increase awareness of pregnancy-related health issues. Targeted educational materials are provided to participants as appropriate. This program also seeks to support the pregnant women in making healthy choices for themselves and their babies during their pregnancy, and to identify women with high risk factors earlier in the pregnancy to better manage and reduce the incidence of preterm labor and preterm birth.