Utilization Review: Addressing the Issues

Utilization review has received its share of criticism in workers’ compensation. In this edition of Inside Workers’ Comp, Genex’s Todd Andrew answers the tough questions regarding UR and explains why it’s a valuable component in the industry.

Tom Kerr (TK): Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry.

I’m Tom Kerr, and today we’re discussing issues in Utilization Review with Todd Andrew of Genex. Todd, thanks for joining us today

Todd Andrew: Thank you very much for having me.

TK: Todd, as you know utilization review has been criticized by some as being a simple cost‑control measure. How would you define it?

Andrew:  You're completely correct. There are definitely those that characterize UR as being nothing more than cost control. But our experience on this side has been that the majority of carriers and employers that we're working with focus under the underlying purpose of utilization review, our core approach to it, which is making sure that the treatment the claimant receives is medically necessary and appropriate.

Those are the two main elements that we focus on ‑‑ the medical necessity of care and the appropriateness of it, to make sure that we're keeping the patient in focus at all times, and the appropriate care in focus at all times.

TK:  Another criticism is that UR services take the decision‑making process out of the hands of providers. Is that true?

Andrew: No, not at all. Similar to how the claims adjuster would retain the oversight and the management of the claim, the treating providers are always going to retain that decision‑making process.

Over the past 20 years or so, there's been a push and a change in medicine, moving towards evidence‑based care. So it's a provider being able to take a look at a treatment and bring not only their clinical judgment and experience, their years of training, their years of practice, but then overlaying on top of that, evidence‑based medicine, looking at the scientific literature, looking at evidence‑based guidelines, and then applying that to the unique patient case.

What we've seen over time is that when utilization review steps in, we're focused more on that evidence‑based approach, where we do have physicians that have that experience, and we do have that academic background and the guidelines, but ideally, we are supporting the decision of the treating doctor and what they want to do.

We only get involved when something seems to be a little bit off. Ultimately, that treating provider is going to create the care plan. They're going to create the direction that they want to go. From our perspective, we're just making sure that it still does follow the lines that evidence‑based guideline dictates.

TK: What impact do you see that UR services will have on claims in the future?

Andrew: It's going to really be dictated by the way that the regulations change and the legislature wants to take it. Ideally, we've always been of that mindset that says, "We only want to have utilization review in place when it's necessary." That's the question, when is it going to be necessary? What we tended to see out in California is that, when utilization review started, we started seeing a sentinel effect. Providers started realizing what was appropriate care and what wasn't, and they started behaving appropriately.

During that period of time, utilization review was used significantly. There was a lot of volume going through. As that provider hit that sentinel effect, the utilization review tailed off. I think that we've seen those ebbs and flows become consistent, both across jurisdictions and across employers when they put things in.

We've reached a steady state in a lot of the jurisdictions that use utilization review. I don't know that things will change much down the road, unless provider practice patterns do change. I think there's always going to be a need for utilization review because it is one of those primary protections for the employer to make sure that the care that is being rendered is appropriate.

I just hope that over time, if providers start practicing in a more evidence‑based approach, that we can minimize the amount of involvement that we have with cases.

TK: Thanks, Todd. In part two of this podcast, we’ll discuss new methods to better incorporate utilization management into workers’ comp programs. Until then, thanks for listening.

Part 2

In Part 1 of our series on utilization review (UR), Genex’s Todd Andrew discussed how utilization review has made a significant difference in reducing unnecessary medical treatments for injured workers. However, the UR process often requires a great deal of administrative oversight. In this edition of Inside Workers’ Comp, Andrew explains what factors necessitate UR and how technology helps streamline the process.

Tom Kerr (TK): Welcome to Inside Workers’ Comp, a regular multimedia series in which subject matter experts discuss problems and offer solutions to top issues affecting our industry. I’m Tom Kerr, and in part two of our discussion, Todd Andrew of Genex, we’ll discuss new methods to incorporate utilization management into workers’ comp programs.

Todd, what necessitates utilization review in a case?

Todd Andrew: Great question. We tend to take a very consultative approach when we work with clients. The first tier of care would be working with the carrier to say, "Are there services, are there providers that we can put a prior authorization plan together for so that when that patient is sitting there with that physician, and that physician wants to do something, that that physician gets automatic approval to go ahead and do that service?"

The second step that we work with the clients, therefore, is to work for what the adjusters can approve. If there are services that can't be pre-approved but are almost always approved if they go before a physician's eyes, we want to enable the adjusters to be able to make those decisions and to approve that care, once again, to try to diminish any delays that might be there.

Only when those two things fail do we actually bring utilization review into it.

TK: OK, so how does the injured worker benefit from UR services?

Andrew: First and foremost, they get appropriate care, medically necessary care, approved as quickly as possible.

The other side of that, then, is if we identify care that's not appropriate for them or that doesn't appear to be medically necessary, then that care doesn't get rendered. I recall specifically a surgery years ago that was being requested, where the treating physician was actually going to cut through an infection to the area that he needed to actually operate on. Our reviewer recognized it and immediately suspended that care until that patient recovered from that infection because otherwise, it would have put the outcome of the surgery in jeopardy.

From our perspective, we're trying to make sure that what's being rendered for that patient is the right thing at the right time to make sure that they're going to benefit to the utmost and get back to health as quickly as possible.

TK: What role does technology play in improving UR services?

Andrew: I think there's three different ways that utilization review can benefit from technology. First and foremost is the optimization of the whole UR process. UR, as a process, has a lot of administrative oversight. A lot of these tasks are very rote. Technology would help us to streamline that process, optimize the rote processes, so that decisions can be done faster, but more importantly, that the amount of time and energy that is spent in utilization review can be focused where it should be.

The second way that I think it benefits is increased compliance, reduction of errors. On our side, we are constantly faced within utilization review of making sure that we get not only timely decisions out the door, but for the most part, that we're going to be compliant with the jurisdiction's rules.

Technology allows us to automate a lot of those processes as well to ensure that we're going to have a review that is timely and compliant with all the prevailing regulations.

Then finally, technology allows us to start to link systems together. We can link into claim systems to make sure that the information that we're pulling forward is the most up-to-date and accurate information on the claim. We can render our decisions and drop it directly over to bill review so that services we approve can be paid timely, or services that are denied are not accidentally paid.

We can tie into case management, where if an adverse decision is rendered, we can actually trigger a case manager to possibly reach out and see if they can get that case moving, and moving in the right direction. Technology really starts to bridge the gap in that medical care model across all those services and is, I think, absolutely crucial to the appropriate approach and the way that medical health care is going.

TK: Todd, thanks for your time. In our next Inside Workers’ Comp, we’ll explore bill review: what’s it all about? Until then, thanks for listening.