By: Ben Roberts, Vice President, Utilization Review, Genex Services
In the spring of 2022, the New York State Workers’ Compensation Board (WCB) rolled out OnBoard: Limited Release, transitioning key utilization review processes from paper to online for health care providers, payers, and other stakeholders. Implementation of the new requirements has become front and center for payers and managed care providers due to the potential to increase efficiency, improve injured workers’ care, and save time and cost by eliminating manual tasks. With this rollout, the WCB expects the OnBoard system to significantly improve the efficiency of the previous systems which required considerable manual work including the manual creation of more than 50,000 Orders of the Chairs each year, scanning more than 900,000 documents, and follow-up on more than 48,000 improper variance requests.1
The new Prior Authorization Request (PAR) process in OnBoard replaces the legacy MG-1, MG-2, C-4Auth, and Drug Formulary Medical Portal processes by requiring electronic submission through OnBoard.
Lessons Learned
Widespread Adoption
Initially, the roll-out resulted in a small number of PAR requests, as providers were getting trained on how to use the portal, but with time and focus from the WCB, provider adherence has increased substantially, and payers and medical review organizations are seeing more and more requests being uploaded into the system. Once a provider has gone through the process of setting up a profile and training staff to complete the submission process, they can use their profile for any injured worker that they are currently treating. The WCB shared that over 43,000 providers had registered for OnBoard by the end of August.2 PAR requests began to increase in frequency towards the end of 2022 and have continued to increase as we have moved into 2023.
Turnaround Time
Another early lesson learned was regarding the timeliness of responding to PAR’s. Under the legacy process, manual forms required the WCB to research each instance where a payer may have failed to respond to the required form in accordance with the required time limits. Under the OnBoard process, in many cases, if a PAR is not properly responded to by the end of the day (11:59 EST) on the due date, it is automatically approved through an automated Order of the Chair notification sent to the parties on the claim or escalated to level three for review by the medical director’s office. This means that anyone providing utilization review services must adhere to the associated time limits set in place by the WCB or risk auto approval of the treatment request.
Ongoing Updates
The WCB has been diligent in providing training, webinars, and notifications to stakeholders to keep everyone current with the ongoing updates and enhancements. Enhancements focused on easier navigation, as well as addressing common scenarios not contemplated in the original design have been particularly helpful for both payers and providers.
Ongoing Challenges
With any technology migration, there are always challenges, and while the WCB has made some great enhancements to OnBoard, there are still items that will need to be addressed including:
Consistency
The updated PAR process has three levels with different user types at each level. Level one can be anyone designated by the payer, level two is performed by the payers physician (peer reviewer), and level three is performed by the medical director’s office. We have observed challenges around consistency across these three levels of review, as OnBoard dictates which decisions, information, and options can be utilized for levels one and two.
Blending Clinical and Administrative Functions
In many situations, the OnBoard portal permits both clinical and claims management tasks to resolve a PAR. For level one, when denying a request for claims-specific reasons such as claim closure, claim controverted, claim withdrawn or cancelled, OnBoard requires documentation that may not be readily available to the designated level one reviewer. Another example is when a review is completed and the treatment is medically necessary, the reviewer can either grant or grant without prejudice (GWP). Granting without prejudice should be limited to scenarios where the payer has filed a denial (First Report Of Injury [FROI-04] or Subsequent Report Of Injury [SROI-04]) in the case and the controversy is still pending; or the body part or condition has not been accepted by the insurer or employer (with or without liability) on a FROI/SROI or established by decision of the Board (GWP in this instance is only valid if made by the level two physician).
It is not uncommon for the reviewer, particularly at level two, to not have access to all the claim-related information that may impact how the review should be granted. Unfortunately, if the reviewer fails to select the correct option, and information is discovered that would impact the claim status there is no way to amend or edit the decision.
Summary
Overall, the roll-out of OnBoard has been successful with significant provider adoption, hundreds of thousands of PAR requests being processed through the portal, and a significant reduction in manual tasks. While it has been successful, it is important to partner with a utilization review company that understands and continues to monitor Onboard developments and changes to ensure compliance. Continued improvements and enhancements based on user feedback will be essential to the continued success of OnBoard and the accomplishing of the goals outlined by the WCB. There is now a significant amount of data related to provider and payer behavior in the prior authorization process and how to efficiently deliver appropriate and necessary care to injured workers which the Board will hopefully begin sharing with stakeholders to allow us to continue to enhance and improve the prior authorization process.
Notes
1https://www.wcb.ny.gov/onboard/
2https://www.wcb.ny.gov/content/main/insurers/ArchivedUpdates/what-payers-need-to-know-20220831.jsp
About Ben Roberts
Ben Roberts joined Genex through the acquisition of PRIUM in 2017 and is responsible oversight of utilization management on a national scale. He has served in various roles in the managed care space including regulatory and compliance management, operations management, and client services roles. Prior to joining Genex, he served as executive vice president and general Counsel of PRIUM, a medical cost management firm.
Roberts received his Juris Doctor from the University of South Carolina School of Law and a bachelor’s degree from University of Georgia. He currently holds a license to practice law in Georgia.
About Enlyte
Enlyte is the parent brand of Mitchell | Genex | Coventry, a leader in cost – containment technology, independent medical exams (IME), provider and specialty networks, case management services, pharmacy benefit and disability management. The three businesses have aligned their joint industry expertise and advanced technology solutions into a combined organization of nearly 6,000 associates committed to simplifying and optimizing property, casualty and disability claims processes and services.
Disclosure:
Enlyte is a WorkCompWire ad partner.
This is NOT a paid placement.