By Dan Maldonado, DC, Clinical Director for Utilization Review and Physician Advisory Services, Genex Services
The success of a utilization review organization depends on the quality of its physician network. UR physicians impact all stakeholders on a workers’ compensation claim when they render a determination of medical necessity. For this reason, it’s important to know how your UR organization recruits and credentials the physicians in its network.
This starts with taking careful measures to verify the credibility of reviewers to ensure good outcomes and prevent fraud. Fortunately, many states require that utilization review organizations (UROs) meet accreditation standards for URAC, the leading credentialing organization for UR. This helps ensure that the URO has initiated a process that assesses the academic and clinical qualifications of a physician to ensure he or she is capable of delivering reviews that are accurate and will lead to the best clinical outcomes. For payers, a URAC-accredited organization is an important first step in determining whether you’ve hired a quality URO.
In turn, best physicians are also drawn to UROs that have URAC accreditation. These professionals see the URAC seal as a sign of excellence that the URO has maintained a solid history of providing accurate reviews and a trustworthy record. Unfortunately, when a URO is not accredited, it may not demand the same standards of its physicians, and that can lead to problems.
Worst Case Scenario
Perhaps one of the most notorious examples of this is the federal case against Spyros Panos, a former orthopedic surgeon from New York who had surrendered his medical license in 2013 on charges of health care fraud. Last year, despite having served a four-year sentence and multi-million payouts to patient victims, Panos was arrested for assuming the identity of another licensed orthopedic surgeon and conducting utilization review for several organizations under this false identity.
When charges were brought against Panos, it rightly caused significant concern in the industry, calling to question the recruitment and credentialing procedures of many organizations. Stakeholders can and will routinely file complaints and grievances that call into question the qualifications of the physician that may have rendered a utilization review determination. When that happens, UROs must provide evidence to state departments and accreditation agencies that proper credentialing procedures were followed and documented. If that’s absent, penalties can be assessed, and certificates or accreditations can be revoked.
This can cause major credibility issues for all involved. Payers are best served in preventing these situations from occurring by thoroughly checking their URO’s recruitment policies and procedures.
Recruitment and Credentialing Process
For UROs, sound UR physician recruitment begins with networking at conferences and other events to meet potential reviewers in person. Also, connecting with physicians through social networks and inviting current in-network physicians to refer colleagues that they think might be a good fit.
To further vet UR reviewer candidates, quality UROs take extra measures to verify their credentials by communicating with state and national agencies to validate important factors such as licensures, board certifications and medical malpractice histories.
When reviewers are hired, UROs should invite the physician to meet with the team face-to-face or through video conferencing. This not only provides another opportunity to confirm identity, but also allows the physician to feel like a vital part of the organization.
You should expect that your URO has not only developed detailed and thorough credentialing policies, but ensures they are followed on a consistent basis. Quality organizations also conduct regular quality audits on the reviews and reviewers, to verify that physicians continue to adhere to all applicable laws and standards that promote the best clinical outcomes from utilization review.
UROs that do their due diligence create a network of physicians who are empowered to apply their clinical expertise to the reviews they complete and are connected to the overall clinical philosophy and direction of the program.
About Dan Maldonado
Dan Maldonado, DC, is clinical director for utilization review and physician advisory services at Genex Services, where he oversees the credentialing, training, and quality assessment of all clinical peer reviewers. Dr. Maldonado collaborates with medical directors and physician advisors to deliver effective clinical direction throughout the peer review operations.
About Genex Services, LLC
Genex Services provides best-in-class clinical solutions that enable customers to transform their bottom lines while enhancing the lives of injured and disabled workers. Genex, a clinical management leader throughout North America, serves the top underwriters of workers’ compensation, automobile, disability insurance, third-party administrators and a significant number of Fortune 500 employers. In addition, Genex clinical services are enhanced by intelligent systems and 360-degree data analysis. Its clinical expertise 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. Genex Services and Mitchell International merged recently to create the broadest continuum of technology and products servicing the auto, workers’ compensation, and disability markets.
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