By: Mike Lemrick, Senior Director of Operations, Utilization Review & IME, Coventry Workers’ Comp Services
You know the punchlines: “The check’s in the mail.” “This won’t hurt a bit.” “We’re from the government. We’re here to help.” Too often, the parties involved in a workers’ compensation claim consider utilization review with the same kind of skepticism. “Yeah, right. You’re all alike….” Injured workers are afraid that they’ll be denied services. Providers expect to have their hands tied. Adjusters may be uneasy because they can’t influence the decision. The common misperception is that payers want to deny injured workers treatments they need and that utilization review is a tool to achieve that. The truth is, both the payer and the injured worker share a common goal: appropriate treatment to foster recovery. Utilization review does not need to be adversarial. When UR is done well, it’s an objective process to help all parties achieve that goal. You can and should be able to trust UR to benefit all workers’ comp stakeholders by helping ensure appropriate care.
Clear up consumer misconceptions
Too many injured workers believe that utilization review is the process by which “bean counters” deny them the services they need to recover. Many don’t understand that the purpose of UR is to protect them from unnecessary tests, surgeries and procedures that could lengthen their recovery times. In fact, many states require workers’ compensation UR just for this reason.
Perhaps those patients would be less suspicious of UR if they knew that nurses—the most trusted profession in America, according to the Gallup Organization1—do the initial reviews for medical necessity, following evidence-based guidelines to support their decisions, and that the nurses certify a majority of procedures they review. Those patients might also feel better knowing that if a procedure is not initially certified as medically necessary, a physician reviews it and reaches out to the treating provider to discuss the request and collect additional information to make sure the correct determination is reached for that injured worker. In some cases, it may be necessary to mutually modify the frequency, intensity or duration of a treatment request in order to bring it in line with guidelines. In cases where the treatment that was initially ordered by the treating provider is deemed appropriate (possibly due to a comorbidity such as obesity, diabetes or heart disease), but is outside of the guidelines, the physician reviewer may be able certify the original treatment plan due to those factors.
If the physician reviewer finds that that the treatment is not appropriate, and the treating provider is not willing to make adjustments, the physician may recommend non-certification. In this case, the determination can be appealed, additional medical information provided, and a second review will take place. The exact procedure for this process varies by state. However, if the nurse and physician reviewers have done due diligence, very few of these decisions will be overturned, because the reviewers have made recommendations that are in the patient’s best interest and are meant to increase the likelihood that the injured worker gets the right treatment. The ultimate goal is for the injured worker to regain self-efficacy, functioning in the workplace and society as close as possible to his or her pre-injury level.
Focus on clinical quality
The argument for trusting UR becomes stronger when the UR partner has a structure in place that is designed to promote consistency and quality of care. That means licensed nurses with clinical experience as well as physician reviewers with board certification in the appropriate specialties. Both the injured worker and the adjuster should be able to trust that the reviewers are objectively reviewing the provided medical records against defensible, nationally recognized evidence-based guidelines, such as the Official Disability Guidelines and state-specific guidelines. An in-house medical director can help ensure quality, not only by taking responsibility for regulatory compliance but through a stronger connection with clinical staff than an outside resource could offer. An in-house medical director can be directly involved in training nurse reviewers, building strong relationships with physician advisors, being readily available to address areas of concern and providing clinical insight into complex cases.
Being able to integrate with other services further supports clinical quality. For example, a case manager who is alerted when a requested surgery is certified can prepare the injured worker with information on pre-operative requirements, post-op procedures, and expectations for recovery. If a procedure is not certified, the case manager can review the treatment plan with the provider to determine what changes might be necessary to move the case forward. When UR is integrated with bill review, non-certified procedures can be flagged for non-payment.
Take a closer look at the differences
The fact that UR is heavily regulated helps give rise to the misconception that “if you’ve seen one, you’ve seen ‘em all.” Although UR programs may look similar, or even the same, in terms of what they offer to meet state requirements, what happens on the back end can be very different. Those differences can impact information flow, turn-around time, interfaces with claims handling, adjuster touch-points, and administrative costs. Those differences can also affect product quality and the risk of penalties for noncompliance. For one thing, in states with regulations specifying how UR must operate, the rules change frequently, therefore compliance is a constantly moving target. To avoid problems, third-party administrators and carriers need to be able to trust that their UR partner is familiar with all the nuances of the regulations from state to state and is completely up to date with them. In states that don’t do their own UR plan audits, national accreditation by URAC and/or Utilization Review Organization (URO) certification as required, provides one indication that the UR partner is making changes as the states make them.
Another consideration is flexibility. Hiring and training nurses takes time, which can make it difficult for third party administrators or carriers to scale up when a large influx of business occurs. Referring overflow to a reliable UR partner with flexible resources and knowledge of the payer’s workflow process can enable you to respond quickly and meet turn-around time requirements. Having these overflow relationships in place before you need them is the best approach, allowing everyone to act quickly when the need arises and as it fluctuates.
Achieving the above requires clinical expertise, sophisticated automation tools, and a robust infrastructure. When a UR partner can offer all those, all parties involved in a workers’ compensation claim can trust that the UR process is a powerful tool to help them reach the best possible outcomes.
About Mike Lemrick
Mike Lemrick is senior director of utilization review and independent medical examination operations for Coventry. With more than 14 years in the workers’ compensation industry, Mike’s experience spans operations, product and systems development, and Account Management. Prior to Coventry, Mike held positions with a national workers’ compensation third -party administrator and a multi-national company both domestically and internationally.
About Coventry Workers’ Comp Services
Coventry offers workers’ compensation cost and care management solutions for employers, insurance carriers, and third-party administrators. With roots in both clinical and network services, Coventry leverages more than 30 years of industry experience, knowledge, and data analytics. The company offers an integrated suite of solutions, powered by technology to enhance network development, clinical integration and operational efficiencies at the client desktop, with a focus on total claims cost.
1Gallup® poll. Honesty/Ethics in Professions. Dec. 5–8, 2013. Retrieved July 29, 2014 from http://www.gallup.com/poll/1654/honesty-ethics-professions.aspx.
Coventry WCS is a WorkCompWire Ad Partner.
This is not a paid placement.