By Steven Cardinale, Managing Director/Co-Founder, CID Management, Inc.
Last week’s post discussed what elements of the utilization review (UR) process should be measured. If the process is properly done, it should help send only those cases that require a review to UR and, at the same time, avoid sending the wrong cases to UR. Now, we’ll look at the use of specialty reviews.
A specialty review, or a specialty-matched review is a UR that is done by someone who has the same credentials, background, and training as the treating doctor. In other words, if an orthopedic surgeon is requesting a procedure, another orthopedic surgeon performs the review. It makes little sense for someone who has never done surgery to review a request for surgery. In the same manner, a request for a procedure by a neurologist is reviewed by another neurologist.
In this way, that is using a specialist to review the request, the reviewer is better able to provide meaningful input regarding the requested services. Also, the specialty-matched reviewer is in a better position to communicate the rationale for granting or denying the request to the treating physician.
Specialty matched reviews, when necessary, are a significant benefit. For example, some UR companies tier their services with a nurse who is doing the first review. If the review calls for a physician review, it is typically handled by an occupational medicine (occ med) doctor. In most cases, this is sufficient. However, an occ med doctor should not be reviewing a request for orthopedic surgery. No disrespect, but he or she doesn’t usually have the skill set to know if someone should pick up a knife; you need someone with the same skills, that is, another orthopedic surgeon to be reviewing the case. Similarly, an occ med doctor should not review a psyche case. That review should involve someone who is trained in the specific field, either a psychologist or a psychiatrist. Having specialty matched reviewers ensures that the right doctor is looking at the claim at the right time.
Are specialty matched reviews more expensive? That depends on the UR vendor. Some consider a specialty match to be a complicated form of peer review. In other words, it is a step above a typical physician review. The vendor subsequently charges more for such a review. However, if a review has to go through several cycles because a nurse could not deny it and the occ med doctor’s review was appealed, the claim will be escalated to a specialty matched review. Consequently, you are charged for two reviews before getting to the one that you really needed. In the meantime, the patient’s condition is likely deteriorating, which extends both disability time and claim costs.
The bottom line is that specialty matched reviews, when required, should mean fewer appeals or turnaround and better outcomes, both clinical and cost wise. After all, you’re supposed to be providing good care and saving money. Using the right technology, and using a specialty matched review when it is appropriate, makes everything happen quickly and cost effectively.
About Steven Cardinale
Steven Cardinale brought 15 years of business and technology experience to co-creating CID Management in 2002. Just prior to CID, Mr. Cardinale served as Chief Technology Officer for iBidCo, an on-line real estate sales site that sold more real estate “sight unseen” than any other, where he crafted a partnership with eBay. An accomplished business, management and technology strategist, he has consulted with Eli Lily, Janus Funds, IBM, PricewaterhouseCoopers, and the J. Paul Getty Museum.
Cardinale holds a degree in Economics from the University of California, Los Angeles (UCLA) and is a graduate of the prestigious Wharton School of the University of Pennsylvania. Email him at scardinale@cidmcorp.com
About CID Management
Based in Westlake Village, California and serving workers’ compensation payers nationally, CID Management is a workers’ compensation utilization management company that offers a unique range of services collectively known as The Clinical Experience. Under The Clinical Experience umbrella, CID provides URAC-accredited utilization review (UR), peer review and peer-to-peer physician case management to provide decisions that support evidence-based care, control medical costs and mitigate risks. CID offers three additional Clinical Experience services; Clinical Help Desk, MD On-Call, and Physician Conversations that help clients get fast and instructive answers to clinical, regulatory and administrative questions to keep claims from stalling. CID can be reached at www.cidmcorp.com or 866-301-6568.