Liability Cost Management » PRIUM Medical Cost Management Services

By: PRIUM  09-12-2011
Keywords: Treatment Provider, Clinical Reviews,

Auto Claims Review


These clinical reviews are conducted to address excessive and even fraudulent medical treatment related to auto liability BI (bodily injury) and PIP (personal injury protection) claims. This is especially true for low-impact accidents with soft-tissue damage, a nationwide issue. The nuances of each jurisdiction (strategies used by claimants to take advantage of the “system” and tools the state allows) are taken into account.

For PIP/MedPay claims, PRIUM ensures appropriate medical services and billing. For BI claims, PRIUM mitigates exposure for what should be paid.

The Program

The purpose of this program is to establish boundaries for treatment that are reasonable, necessary and related to the accident. These conclusions are drawn from the statutes of limitation enforced by each individual jurisdiction. The program focuses on the following components:

  • Early engagement with the treatment provider to proactively establish a reasonable treatment plan. 
  • Works with the treatment provider(s) to complete the treatment. 
  • Leverages Evidence-Based Medicine (EBM) as best practice for treatment scope. 
  • Establishes a sentinel effect for ongoing treatment. 
  • Identifies up-coding, un-bundling and excessive fee billing practices. 
  • Replaces the need for an IME (Independent Medical Exam).

Keywords: Clinical Reviews, Treatment Provider,

Other products and services from PRIUM


Workers’ Compensation Cost Management » PRIUM Medical Cost Management Services

The MSA Clinical Review is provided in support of the MSA settlement process to document the most appropriate current and long-term pain management regimen in a way that the Centers for Medicare & Medicaid Services will approve, representing a consensus among all parties on the best approach.


Utilization Review/Management » PRIUM Medical Cost Management Services

They facilitate the proactive management of clinical resources — mandated by either the jurisdiction or the payer — and are used to bring an injured worker back to health and return them to work. To provide either a claims adjuster or a nurse case manager direct access, via either e-mail or by phone, to a clinician in order to have clinical questions answered or general guidance provided.