Workers' Compensation Specialty Programs
EastPoint Insurance Group has designed its Workers' Compensation plans' specialty programs to save you money and provide the highest quality care for your employees.
EastPoint Insurance Group and the client examine and analyze the quarterly and
annual reports. The trends of the client can often show what types of risk
management services and presentations are needed. Darrell Trent, Chief Risk
Officer, is available to present on a myriad of issues associated with
workplace injuries. Trent has been with EastPoint as a risk manager for 28 years. Risk management
services are available upon request. EastPoint offers the first
twenty-five (25) hours of risk management services at no charge (per year).
If the first twenty-five (25) hours of risk management services are
exhausted in a given year, the client can request additional risk
management services at competitive pricing listed in the Rate Quotation
EastPoint Insurance Group utilizes Preferred Medical Network (PMN) for pharmacy
services. EastPoint, in partnership with PMN, is committed to providing the finest managed prescription
program available. In order to offer our clients a total seamless
prescription managed care product, PMN has established an alliance with
National Pharmaceutical Services (NPS). NPS provides a national pharmacy
network along with prospective, concurrent and retrospective drug
utilization review with formulary and rebated administration. The net
result of our efforts is an all-inclusive product that will improve the
quality of life for all participants.
EastPoint Insurance Group uses PMN to allow our clients a prescription drug
system that will not only satisfy current requirements, but position our
clients to take advantage of future health cost containment opportunities.
Utilizing PMN gives our clients a very high level of control, integrity and
case management. The result is better care for beneficiaries at a lower
In order to effectively provide the finest customer service, the concurrent
drug utilization review program screens prescriptions for both mail order
and network retail pharmacies. Employees have the opportunity to select
from a mail order program or National Participating Network of Pharmacies.
Either of these programs offers a significant price reduction from the
Kentucky Department of Workers’ Compensation fee schedule.
Managed Care Solutions
EastPoint Insurance Group contracted with medical care providers to develop
WorkComp Network, a full service workers’ compensation managed care
organization (MCO) for managed care services as of February 1996.
Medical case management is conducted by nurses experienced in occupational
medicine, disability and medical case management. Case management is
recommended, for the most effective outcomes, to begin at the time of the
second office visit when ongoing treatment is recommended.
Financial and lost time thresholds can also be established based on the
specific needs of clients to indicate specific levels of medical management
involvement. Case management is primarily conducted telephonically with
field case management being implemented only when appropriate. Medical
management services include scheduling of appointments, referral to
gatekeeper physicians, facilitating referrals to specialists and
communication with employees, employers, payers and providers. The nurse
case manager monitors for appropriateness of treatment plan, quality of
care, cost-effective nature of treatment and for the patient’s compliance
with treatment plan.
On-site case management is only recommended if the severity of the injury
or other factors warrant. The adjuster, the case management nurse and/or
the Claims Manager may recommend on-site case management. EastPoint Insurance
Group contracts with an independent contractor for on-site case management.
If approved by the employer, the nurse case manager will attend medical
visits with the claimant to ensure that all questions are answered, all
issues are addressed and follow-up appointments are made. Due to the
expense of on-site case management, this is recommended only in extreme
circumstances and with the approval of the employer.
Utilization Review Solutions
The Kentucky Department of Workers’ Claims certified EastPoint Insurance Group (through its sister company KHA Solutions Group) as
a full-service Utilization Review Agency in 1996. EastPoint handles all medical bills, medical bill review, medical management and
utilization review by an in-house nurse case manager. We
utilize a panel of utilization review physicians. The utilization review physicians are independent
contractors utilized by EastPoint Insurance Group, which does
not have any financial incentive or ownership of the physicians.
Utilization Review is another tool utilized by EastPoint to
ensure medical necessity, work relatedness and reasonableness of a
treatment plan. Pursuant to the regulations, a claim will be submitted for
utilization review when:
- A medical provider requests preauthorization of a medical treatment or
- Notification of a surgical procedure or resident placement pursuant to
803 KAR 25:096 treatment plan is received;
- The total medical costs cumulatively exceed $3,000;
- The total lost work days cumulatively exceed thirty (30) days; or
- An arbitrator or Administrative Law Judge (ALJ) orders a review.