By Cathy Glade RN, Senior Vice President, Genex Services
Utilization review (UR) has become a hot issue in workers’ compensation recently, with states such as California making changes to its regulations in an attempt to reduce treatment delays and ensure quality by requiring utilization review organizations (UROs) to attain accreditation.
That leaves employers and carriers in a tough spot. Under increasing pressure to choose the right process, you’re challenged to find a URO that meets the underlying purpose of utilization review — reducing the use of unnecessary or inappropriate medical services without jeopardizing high-quality care.
Perhaps you’re doing your due diligence by narrowing the search to managed care programs with strong reputations. That’s a good start, but you want to verify the URO addresses process delays and quality assurance.
Overcoming the overload
That’s quite a challenge to overcome considering the unwieldy workers’ compensation claims process. Adjusters constantly pushed to settle claims quickly, entrenched organizational practices, and noncollaborative decision-making often create delays.
UR decision-making begins in the claims approval process, when adjusters are deciding which services should be approved or sent for review. This involves extensive administrative oversight, including collecting medical records, creating correspondences that go out to the various parties, and documenting the entire process as it happens. It demands a URO program capable of helping these professionals make the best decisions, especially for more difficult claims, within their busy and complicated workloads.
To overcome these issues, successful UROs have integrated technology to streamline the process and help adjusters decide when to approve or send for UR. A high-quality program utilizes technology to reduce administrative overhead and extend a company’s overall medical strategy to every desk. It factors in regulatory issues, evidence-based and company-specific guidelines in developing solutions to help adjusters decide what services should be approved and which should be sent to UR. This also cuts research time in ensuring compliance which reduces the likelihood of liability. The best automated programs, will provide UR decisions within 1.7 days.
What about quality?
While intelligent systems can offer superior technology to help clinicians make better decisions, there are other quality issues you should assess when choosing a URO platform. This includes seeking out companies that have earned the stamp of URAC accreditation. URAC UROs have demonstrated their adherence to quality standards reflecting best practices. In fact, several states have designated URAC as their accreditor of workers’ compensation utilization review.
To obtain accreditation, organizations must go through a lengthy process which includes procedure and operation examination designed to extensively evaluate their program, ensuring processes meet widely recognized national standards and respect patients’ and providers’ rights. Accredited organization must meet quality standards in areas such as clinical review, access, timeliness and the handling of appeals.
Empowering, Not Replacing Decision-Making
It’s important to note that UROs that utilize technology and meet accreditation standards can greatly assist in the utilization review process, however, they don’t replace the experience and knowledge of the professionals making the final decisions. Ultimately, the treating provider will adhere to guidelines when appropriate, but will also use his or her best judgment in making that determination based on the needs of the injured worker.
Reducing treatment delays is paramount to integrated programs where return to work in some capacity is an important part of the recovery process and should be the expected outcome. In the end, the best UROs do not replace the claims and clinical professionals in the UR process, but give them the tools best designed to help injured workers return to their jobs safely and efficiently.
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, automobile, and health care systems.
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This is not a paid placement.