By: Cathy Glade, RN, Senior Vice President, Genex Services
It’s no secret that adjusters are among the hardest-working individuals in the workers’ comp industry. They are charged with the seemingly impossible task of making important, yet fast decisions that meet regulatory requirements and performance standards that affect each injured worker whose claim crosses their desk.
Adjusters who are tasked with closing cases quickly may be pressured into making decisions without the best tools at their disposal. When this occurs, it increases the likelihood of mistakes in an injured worker’s course of treatment, which can also lead to disputes and possible litigation.
This can especially be troubling for cases requiring utilization management (UM). Though UM has made a significant difference in helping reduce unnecessary medical treatments for injured workers, simple errors can cause delays in treatment, which could lead to a longer return-to-work period.
Much to do, little time to do it
The utilization review (UR) process requires a great deal of administrative oversight. This includes collecting medical records, sharing correspondences and documenting the entire process as it is happening. Adjusters or administrators must also keep current with the workers’ comp compliance rules of various states. In many cases, these involve rote tasks that actually delay decision-making.
While many claims do not require UR, ones that do should use evidence-based guidelines, such as ODG or ACOEM, on each claim. Rules and decision criteria should be adapted to meet the specific needs of the company’s industry and goals. When guidelines are flexible, current and, most importantly, uniformly and consistently applied, costs decrease and outcomes improve.
How technology can help
But how can adjusters or administrators assure that all of their cases meet these requirements? Automated technology streamlines and automates previously burdensome manual processes. Lightweight, software-as-a-service (SaaS) platforms optimize outdated rote processes to hasten accurate decision-making. More importantly, these programs help reduce the amount of time and energy spent in utilization review and help ensure approved, appropriate care for injured workers.
Such technology links into claim systems to ensure the information pulled forward is the most up-to-date and accurate information on the claim. The system renders a decision based on guidelines and payers’ unique rules and processes it directly to bill review so approved services can be paid in a timely manner or, conversely, not accidentally paid if the services are denied.
Automated technology can also be tied into case management, so if an adverse decision is rendered it can trigger case management intervention to help get the case moving in the right direction. This takes the emotional guesswork out of managing claims and supports and enhances rapid communication among adjusters and case managers.
Finding the right balance
While utilization review is not required in some cases, having the right tools available can go a long way in improving workers’ comp decisions. A recent review of a large employer who used automated UR for its workers’ comp claims showed that 98 percent of its medical decisions were upheld versus the 91 percent industry average. The best automated programs can also provide a UR decision in less than two days.
Best of all, program automation can eliminate administrative burden, streamline processes and empower adjusters and administrators to make appropriate, consistent decisions on every claim. When highly-specialized technology and configurable processes are employed, you can effectively extend the medical director’s strategy to every desk.
About Cathy Glade
Cathy Glade, RN, is senior vice president of utilization management at Genex Services, where she oversees Telephonic Case Management, Utilization Review, and Physician Advisor services, URAC-accredited utilization and case management programs. Ms. Glade joined the company in 1986 as a hospital bill review supervisor and has held management positions of increasing responsibility.
She has more than 25 years of workers’ compensation utilization management experience, as well as 10 years of clinical nursing experience, including the management of nurses and ancillary medical staff in a clinical setting.
Ms. Glade earned her bachelor’s degree in nursing from the University of Texas and is a registered nurse.
About Genex Services, LLC
Genex Services is the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines. Genex is a managed care leader with more than 2,900 employees and 47 service locations throughout North America. The company serves 381 of the Fortune 500 companies as well as the top workers’ compensation and disability carriers and third-party administrators in the U.S. In addition, Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. The company consistently drives superior results related to medical, wage-loss, and productivity costs associated with claims in the workers’ compensation, disability, health care and automobile systems.
Genex is a WorkCompWire Ad Partner.
This is not a paid placement.