8m ago

Are your injured workers getting the right care, at the right time, with the right results?

If you are using One Call for your home health claims, the answer is yes! Building upon the success of our industry-leading Physical Therapy Gold Standard Review program, we set out to replicate a similar process to enhance clinical oversight for home health claims.

Let us introduce you to our Home Health Gold Standard Review (GSR)! The Home Health GSR provides additional clinical oversight from a registered nurse (RN) on our managed claims. The RN Clinical Reviewer conducts a peer-to-peer call to confirm the right level and quality of care is provided to injured workers. The Home Health GSR is comprehensive and covers all services on the referral (i.e. nursing, home health aide, equipment, medical supplies and in-home therapies).

Through our Home Health GSR process, we provide several opportunities in home health to make the right recommendations, at the right cost, to put the injured worker on the appropriate path to recovery.

Let's take a deeper look at the Gold Standard Review:

When are Gold Standard Review red flags triggered?

  • 2 weeks into in-home short-term rehab
  • When care exceeds anticipated severity guidelines
  • 60-days after LIFE Assessment® referral
  • Claimants with at-risk diagnoses
  • 60-days post new catastrophic claim
  • Every 6 months for long-term care files
  • As requested on new or existing files by the nurse case manager

How does the Gold Standard Review process work?

  • On-staff registered nurses review all files associated with the claim and when a red flag is triggered, the review process is initiated.
  • A peer-to-peer call is made to ensure the patient is receiving the appropriate level and quality of care. If additional services or products are needed, further discussions will occur for discharge planning and recovery.
  • The GSR recommendations are communicated to the nurse case manager and adjuster for review to agree or disagree with the new level of care for the patient.
  • Upon approval, our care coordinators manage the new orders and implement the revised recommendations for the patient’s care.
  • After two weeks, a follow-up call is made to ensure the GSR recommendations were the right level of care, at the right time and at the right cost.

If you would like additional information or have any questions please reach out to our team of clinical experts at clinical_leadership@onecallcm.com.

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