UTILIZATION REVIEW A Dependable Cost Cutting Tool in a Changing Landscape

Change is inevitable for self-insured employers.  More control over insurance programs means keeping up with a fast-changing legislative environment that’s inherently out of an employer’s hands.  So as states grapple with both healthcare and workers’ compensation reform, employers wait in the wings to figure out their next move. Recently, many steps have been made to protect the patient that keep self-insured employers on their toes.

Just last year, the Patient Protection and Affordable Care Act (PPACA or PCA) of 2010 was passed as an answer to public pressure for healthcare cost containment, and also as a way to prevent Americans from incurring financial ruin due to medical costs. Similarly, workers’ compensation laws – administered on a state-by-state basis – have been designed to protect workers and employers from excessive costs due to injury liability and litigation. While these mandatory requirements may seem restrictive to self-insured employers who value control, employers can take the reins back by developing compliance strategies to limit their risk and maximize cost savings. One tool that helps achieve both objectives is Utilization Review (UR). By preventing injured workers from receiving unnecessary treatments, including expensive surgery, excessive medication or unwarranted physical or occupational therapy, UR remains an invaluable piece in the medical cost containment puzzle.

GOING BEHIND THE SCENES OF THE UR PROCESS

In order to objectively keep claims under control, UR is employed during the period between injury and return-to-work.  UR is the process of gathering medical information to determine whether or not a requested treatment is medically necessary, and it can be managed by an employer’s claims department, given the appropriate certifications and resources, or through a state licensed, third-party UR company.

The UR process begins when a treating provider submits a request for a treatment and related documentation for either concurrent treatment (during), prospective treatment (pre-certification), or retrospective treatment (after).  A pre-certification for emergency treatment is not required, but may be subject to a retrospective review, depending on the state. The UR organization reviews the request for treatment, typically using nationally-recognized evidence-based guidelines – built on documented research data – and either authorizes, denies, modifies or delays a treatment.

The UR organization’s first line of reviewers – a pre-clinical reviewer (PCR) and a registered nurse (RN) – will either: (1) authorize the treatment, or (2) forward a treatment request to a peer reviewer, which is a licensed medical provider often of the same specialty as the requesting provider. After examining all submitted documentation and attempting to speak directly to the requesting provider on the phone, the peer reviewer will make his or her final determination. If a recommended treatment is disputed, the peer reviewer will offer a clinical explanation of the decision and provide appropriate treatment recommendations to the requesting provider that follow commonly accepted evidence-based guidelines.
Fourteen states regulate the UR process in order to maintain a system that fairly and objectively authorizes, modifies or denies treatment requests. The aims of the implemented polices include:

• Setting deadlines for determinations to facilitate fast decisions that get patients through the healthcare system quickly
• Allowing workers to get the appropriate care they need so they can go back to work
• Ensuring reimbursement to providers for medically necessary services

ADVOCATING FOR THE PATIENT AND FOLLOWING THE RULES

Many states have adopted the timeframes and guidelines set by the Utilization Review Accreditation Commission (URAC) – a nonprofit organization that sets national standard policies for companies involved in the UR process. According to the URAC website, the policies are developed by various stakeholders, including providers, healthcare organizations, insurers and the public interest. An organization must be compliant with the policies and procedures set by URAC to be accredited by the organization. Requirements for accreditation also include two quality improvement projects at any given time and onsite visits to determine URAC compliance.

Specific rules and guidelines for the UR process set by each individual state legislature supersede URAC’s recommendations and standards. For example, URAC’s deadline for a prospective treatment request determination is 15 calendar days from the date of receipt. A UR organization reviewing a workers’ compensation claim in California has five business days to complete the UR review. It’s the UR organization’s responsibility to keep up-to-date on the state-specific rules and changes.

If there’s not enough medical information to make a treatment decision, most states give a one-time deadline extension. Since decisions are almost always backed by evidence-based research, a treatment request is often delayed due to limited documentation. The UR process allows requesting providers to advocate for patients through the appeal process, in either an expedited or standard appeal. If a requesting provider disagrees with the UR determination, they are given the opportunity to make their case by either submitting additional medical documentation or requesting to speak directly with a new peer reviewer.

GETTING EMPLOYEES BACK TO WORK BETTER AND STILL SAVING MONEY

The goal of UR is to ensure that treatments are medically necessary and appropriate first and foremost. The administration of workers’ compensation claims is complicated by regulatory compliance matters and can leave an employer financially vulnerable. Self-insured employers that invest in the UR process as an integral component of managing claims, particularly large claims, can cut down on excessive and unnecessary treatments, thus reducing costs. More importantly, the UR process expedites the return of a productive worker by directing injured workers only to treatments that are needed and related to their work injury. In a constantly changing landscape, UR acts as a reliable guiding force to help you manage your employees’ health and medical costs.

About The Author

Suzanne Berman is a Utilization Review Nurse in the Medical Review Unit of Rising Medical Solutions, a  Chicago-based medical cost containment and care management company. Prior to Rising, Berman gained critical clinical expertise working as a Surgical Staff Nurse at Northwestern Memorial Hospital, where her specialty was Orthopedic and Trauma.  She’s a Registered Nurse in Illinois and Texas, and a member of the Association of Peri-Operative Registered Nurses. Berman has a master’s degree in Public Policy and Administration from Northwestern University, and holds a Bachelor of Science in Nursing from the University of Pennsylvania.