Medical management—utilization review specifically—has historically been handled manually, and tends to require a great deal of administrative oversight and dependencies on the adjuster. The limitations of manual processing often result in delayed utilization review decisions delivered to the injured worker at the other end of the claim. These manual processes can create task-oriented environments that are cumbersome, costly and time-consuming. In today’s age of innovation, data and automated technologies may be the key to managing and improving medical management in workers’ compensation claims.
Enhancing the Entire Medical Management Process
Technology can help improve medical management by enhancing the medical management process. For example, utilization review can require a lot of administrative oversight and consists of many repetitive tasks. Technology tools could be leveraged to help streamline and automate these often rote processes. This kind of automation can help improve time efficiencies for utilization review teams.
Other Ways That Technology Could Help Improve Medical Management Include:
- Streamlining communications between stakeholders involved in a case
- Increasing compliance with mandated turn-around times and reducing the impact of human error
- Supporting integrations and linkages between systems
Streamline Communications Between Stakeholders Through Highly Automated Business Rules
Utilization review cases have the potential to be routed to multiple stakeholders either for review, to add case notes or to provide additional oversight tasks. To ensure that the right stakeholder receives a case in a timely manner, technology can create automated workflows and routing to speed up communications between all those involved in a case. For example, utilization review nurses are qualified to approve medical necessity requests but are not permitted to deny requests. This does not mean, however, that a nurse is needed to review every utilization review request in order to identify which requests should be routed automatically to a physician advisor for a second level review or peer review. Medical directors and utilization review teams can use data analytics to predict the types of requests that should be routed to a physician advisor, for example, hip, back, knee or other injuries that are typically more complex. Furthermore, technology could be used to build out custom rules within workflows that are client-specific and adhere to national or state-mandated jurisdictions.
Increase Turnaround Time Compliance and Reduce Impact of Human Error
Let’s take a look at an example that illustrates the need for automation in utilization review to ensure timely decisions that are compliant with state-mandated and jurisdictional rules and regulations get out the door in a timely manner. Often, utilization review turnaround times and due dates are highly monitored by either compliance regulations or best practice standards. The jurisdiction due date for utilization review cases is as critical as the due date for issuing indemnity payments to injured workers. And while not all states have an established turnaround time for utilization review decisions, it is critical to have a ‘due date’ built into the utilization review workflow in order to deliver timely medical decisions. In a state that may not mandate a specific turnaround time for completing cases, one could consider setting an ‘automated due date’ within their workflow to align with URAC criteria. In this example, the automated due date would help ensure compliance with URAC standards—an independent nonprofit organization nationally recognized in the utilization review community that provides standards and criteria to help ensure high-quality healthcare.
Integrate and Link to Other Systems to Get a 360 View Into a Claim's Past and Help Predict Forward Trajectory
As more solutions become integrated with one another, information, in-depth data analytics and insights can reveal where a case has been and where it has the potential to go. For example, claims data, medical bill review, utilization review, case management and pharmacy benefits management systems that are connected help piece together a complete holistic picture of a claim. All data points and information gathering across these areas help tell a story about the claim as a whole, which provides guidance in how to proceed and intervene with the necessary tools to mitigate potential pitfalls. With this intelligence coming from each of these complementary avenues, one can formulate an approach that will help yield better results for claims professionals and more importantly the injured worker. Mitchell is a partner to the medical management and workers’ compensation markets offering end-to-end cost containment solutions, which include technology-enabled clinical services. You can learn more about Mitchell’s medical management program and the ReviewStat medical management platform here. This article was featured first in WorkCompWire.