By Dr. William Hopper, CMO, MediCall
With the recent passage of legislation in both Workers Compensation, Federal and private health plan arenas, more attention is being paid to the rising cost of increasingly expensive and often times unnecessary healthcare services. Utilization Management is one of the mainstays of resources to deal with combating unnecessary utilization. The development and expansion of evidence-based effectiveness studies is one of the most significant advances in assuring that utilization management can more effectively direct the right patient to the right service at the right time. More and more, providers have fewer counter arguments to the proven effectiveness of these guidelines and effectiveness studies.
According to the Texas State Auditor’s Office Report Number 11-0111 dated November 2010, the following issues were found:
“Significant process and information issues at the Division of Workers’ Compensation (DWC) within the Texas Department of Insurance (TDI) significantly inhibit DWC’s ability to monitor the quality of health care in the workers’ compensation system.
The issues are in four primary areas:
- Unreliable information.
- Weaknesses in complaint processing.
- Weaknesses in the medical quality review process.
- Weaknesses in the enforcement and sanction process.
These issues increase the risk of (1) injured workers receiving unnecessary medical procedures and (2) overutilization within the workers’ compensation system. “
This analysis should raise concerns as to unnecessary utilization of health care services. In addition, interventions are also associated with additional morbidity. All of these factors make the case for applying the most current state of the science utilization review resources.
The choice of an effective utilization review process is critical for an insurance company to survive and thrive. An initial step is to determine the range of primary client goals. Regular communication is invaluable in assuring that there are no incorrect assumptions. The goals should be clear, concise and operational. These goals then need to be understood by the UR department,and should also be reviewed at least annually.
A critical factor in effectiveness of utilization management is the consistency with which the staff approaches and performs their duties. I have witnessed the ineffectiveness of inconsistency and I can honestly say that I feel the effort put into developing and monitoring and implementing consistency is an investment that reaps benefits and rewards.
Key areas to address with your UR Department or vendor should include:
- Accuracy
- Consistency
- User friendliness
- Responsiveness
Here are some essential elements of an effective utilization review program:
- Establish and communicate your goals to your UR team
- Recruit and retain effective personnel
- Robust and standardized training, monitoring and error correction
- Efficient, user friendly software platform
- Application of evidence-based medical necessity guidelines
- Consistent work product
Notes:
1 http://www.sao.state.tx.us/reports/main/11-011.html
Biography for Dr. William Hopper
Dr. Hopper has been CMO of Medicall since 2010, after serving as the National Medical Director of the Concentra Physician Review program for 4 ½ years. He brings to the organization over three decades of experience in occupational medicine, medical management, and family medicine.
Dr. Hopper’s clinical experience includes solo family practice, medical groups, including Sutter Medical Group of Santa Rosa, the Permanente Medical Group of the Northeast, the Vancouver Clinic, Lifelong Medical Care (Berkeley, CA), US Healthworks ,Concentra and has expertise in clinic-based occupational, urgent care, family and addiction medicine. He has developed and managed utilization and quality management programs for hospitals, medical groups, IPAs, MSOs and health plans in California, New York, North Carolina, Washington State, and Oregon. He has extensive experience in the development and application of electronic health records, quality and practice performance improvement programs, evidence-based medicine, billing fraud, practice protocols, and regulatory compliance.
Certifications:
- Certified Physician Executive, The Certifying Commission in Medical Management
- American Board of Medical Management
- American Society of Addiction Medicine
- Fellow of the American Academy of Family Physicians
- Diplomate of the American Board of Family Medicine
- Diplomate of the American Board of Medical Examiners
About MediCall
Headquartered in Pleasanton California, MediCall is a specialized clinical services provider, utilizing certified nurses, physicians, and pharmacists to support the medical management, workers comp, and specialty services segments of the US healthcare market. By combining the ideal mix of an experienced US based management and client services team to oversee their U.S. and offshore based clinicians, MediCall is consistently delivering guaranteed high quality, cost effective clinical services to their clients.