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Utilization Review

In Search of a Great Peer Review

Peer reviewers can have a significant impact on the outcome of a claim. That's why it's worth making a commitment to identify only the best and most effective peer review services.
By: | October 31, 2014 • 5 min read
peer review

Have you noticed the increasing importance of peer review services? With medical and narcotic utilization on the rise, peer reviewers can have a tremendous impact on the outcome of a claim. So, how can you ensure that your search for great peer review services is successful?

Consider this: peer review companies have two customers: the peer reviewer and the payer and your search must ensure that they have appropriately focused on both.

The Peer Reviewer Customer

For the peer reviewer the company that has recruited them must provide the tools necessary to facilitate their work processes so that, as one Peer Review company told me: “Physicians can just be physicians.”

If you want the best medical professionals reviewing your treatment requests or having conversations with the treating provider on your behalf on your most difficult claims, then they must have access to their work anywhere, anytime. “Great” peer reviewers are most often “great” practicing physicians who are very busy and might want to be able to perform their peer review at odd hours of the day or night. The technology must be reliably available more than 99 percent of the time in order to ensure that jurisdictional timeframes are met.

Peer reviewers need easy, well-organized access to all of the relevant information on a case including:

  • Prior medical records,
  • Actual diagnostic images
  • Prior utilization reviews and recommendations
  • Automated and integrated guidelines relevant to each diagnosis
  • State specific regulations.

Peer review companies should have technical, regulatory and clerical support readily available to the peer reviewers. To ensure that their time is used wisely, assisting reviewers with the scheduling of appointments with the treating physicians for peer-to-peer discussions can be very important.

Making the right decision on medical care requires time and energy. Often there is a great deal of medical history to slog through to ensure peer reviewers have the right clinical understanding of a case. If the reimbursement to the provider is a flat rate that does not take into consideration the amount of material there is to review on a particular case, the reviewer will skim the material to get an idea and then make a decision. But previous medical history is a critical component to a peer reviewer’s medical necessity/appropriateness decision.

A “great” peer reviewer will be able to effectively engage with the treating physician and have a fruitful, productive conversation.

Consider the example of an injured worker with a knee injury. The MRI shows the tear and the treatment request meets all the guidelines. However a review of the very extensive medicals demonstrates that this same injured worker has had this surgery several times previously without any benefit. A “great” peer reviewer would have read all the medicals and would have known that, on an MRI, a meniscus tear looks just like a scar from previous surgery. Without any benefit from the previous surgeries, more surgical intervention is not indicated.

The Payer Customer

For the payer customer, the peer review company must make certain that reviews are completed with the highest quality for a reasonable cost. This means that they have to provide all of the support services noted above and have clinical integrity as a core value. What should you be looking for?

The peer review company must demonstrate a thorough and extensive recruitment and credentialing process for peer reviewers. This process should not only include the usual primary source verification but assurance that peer reviewers have demonstrated clinical insight: the ability to find a balance between their clinical experience and evidence-based guidelines.

Two of the most important skills in the art of peer review are communication and interpersonal skills.  A “great” peer reviewer will be able to effectively engage with the treating physician and have a fruitful, productive conversation. This is especially true when you are using peer review on your legacy/complex claims where the peer reviewer is attempting to obtain agreement to a significant change in treatment or prescribing plans.

One peer review company explained it to me this way: “When you are doing jurisdictionally mandated UR, the treating provider is expecting your call; when you are doing a retrospective review on a complex claim, you are surprising the provider and ‘great’ communication skills are critical.”  Because these skills do not necessarily go hand-in-hand with clinical skills, your peer review company must have a method to measure the level of skill for each of their peer reviewers and be willing to train when necessary.

The peer review company needs to have a formal quality assurance process that ensures that another clinical professional reviews each peer review letter or report.  You want the company to ensure that the review has sound clinical reasoning that is appropriate and consistent from a diagnosis, guideline and medical records standpoint, has appropriate spelling and grammar, has answered all the questions posed by the adjuster, has the treating provider’s perspective/agreement when appropriate and has met all jurisdictional requirements.

In order for you to be certain such a program is in effect, the peer review company needs to be able to demonstrate that it is tracking the QA statistics/issues/complaints for each of their contracted reviewers in order to assist or retrain those with frequent issues or replace those unable to perform at the expected level.

And last but certainly not least, the peer review company should be providing meaningful outcome reports that identify the impact of the peer review Program on your WC Program. You need to decide what goals you are setting for this program. Is it all about the number or percentage of treatment denials or the reduction in the number of pharmaceuticals an injured worker is taking?  Or are you more interested in overall program impact, e.g., reductions in average cost per claim or overall medical spend? Whatever goals you set for this program, your peer review company should be able to assist you to understand their impact on those goals.

Ask yourself: What can I do to bring my organization’s peer reviews from good to “great”?

Maddy Bowling is a principal in Maddy Bowling Consulting, Inc., a WC consulting firm. Bowling has 35 years of broad-based executive management experience within operating, corporate and consulting environments spanning the workers' compensation injury management industry. She can be reached at or 630-682-3169.
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Big Data

Can Predictive Analytics Help Prevent Injuries?

Experts see tremendous potential in using predictive analytics for to predict the probability of injury and disease.
By: | October 31, 2014 • 3 min read

Can predictive analytics help reduce workplace risk? It’s a question researchers are hoping to answer as they seek input from health and safety practitioners.

“Clearly, there is tremendous potential for improved prevention if accurate predictions of injury and disease probability are possible. It seems likely that if injuries can be predicted accurately, they can be prevented,” wrote Dr. Gregory R. Wagner, senior advisor to the director of the National Institute for Occupational Safety and Health. “But there are many barriers to employing predictive analytics to improve occupational safety and health.”


In a recent science blog posted on the NIOSH website, Wagner explained the many possible applications of predictive analytics to safety and health, challenges to fully utilizing its potential, and the type of help the agency is seeking from experts who are or would consider using predictive analytics in their practices.

PA, as he explained, is “the application of recently developed analytic techniques to build, test, refine, and apply algorithms in an effort to, as Eric Siegel famously wrote, ‘predict who will click, buy, lie, or die.’”

In the retail environment, PA is used by Amazon to inform customers of a particular product that may interest them; Netflix to recommend a particular movie to a customer; and credit card companies to target customers with specific incentives to buy the card. Some police departments use PA to improve crime prevention by assigning patrols to specific locations.

“NIOSH has been exploring the potential application of predictive analytics and related approaches to reducing risk of death, injury, and disease from work,” Wagner wrote. “The data potentially relevant to predicting injury or disaster are plentiful: prior safety experience; a worker’s age and time in a specific job; time during a shift and hours worked during the prior day, week, or month; geographic location; how recently a workplace inspection occurred and what the results were; season; enterprise profitability; the presence of an injury prevention program; union representation of the workforce; and on and on.”

But using PA or big data to predict and prevent workplace injuries also faces potential industry pushback. “Some large workplaces have large quantities of relevant data available but do not know what to do with it,” Wagner explained. “Others may have the potential to analyze and react to their data, but they may lack the motivation to apply analytics beyond sales and marketing.”

“Some large workplaces have large quantities of relevant data available but do not know what to do with it.” — Dr. Gregory R. Wagner, senior advisor to the director of the National Institute for Occupational Safety and Health

Smaller companies, he noted, may lack sufficient data or the resources to use it. There are also privacy concerns about the potential use of available data. “And some employers may believe that they are doing just fine without the benefits of prediction — that the potential benefit isn’t worth the effort.”

Predicting health and safety risks depends on having a sufficient amount of quality data, trained analysts to use it, and the ability to post questions and identify situations that may benefit, Wagner said. Major disasters such as oil rig failures or plane crashes could be difficult to predict because they are rare. “But it is likely that other workplace problems from long-haul truck crashes to chemical line leaks could be anticipated and prevented by employing existing sensor technologies and predictive analytics.”


While some companies are beginning to use predictive analytics in various ways, NIOSH is seeking answers from industry participants to the following questions:

  • What circumstances could benefit from the application of predictive analytics?
  • Do you know of situations where predictive analytics is being used to improve workplace health and safety?
  • What are the barriers to adoption of advanced analytics for occupational health and safety?
  • What can be done to overcome these barriers?
Nancy Grover is co-Chair of the National Workers’ Compensation and Disability Conference and Editor of Workers' Compensation Report, a publication of our parent company, LRP Publications. She can be reached at
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Sponsored: Liberty International Underwriters

A Renaissance In U.S. Energy

Resurgence in the U.S. energy industry comes with unexpected risks and calls for a new approach.
By: | October 15, 2014 • 5 min read

America’s energy resurgence is one of the biggest economic game-changers in modern global history. Current technologies are extracting more oil and gas from shale, oil sands and beneath the ocean floor.

Domestic manufacturers once clamoring for more affordable fuels now have them. Breaking from its past role as a hungry energy importer, the U.S. is moving toward potentially becoming a major energy exporter.

“As the surge in domestic energy production becomes a game-changer, it’s time to change the game when it comes to both midstream and downstream energy risk management and risk transfer,” said Rob Rokicki, a New York-based senior vice president with Liberty International Underwriters (LIU) with 25 years of experience underwriting energy property risks around the globe.

Given the domino effect, whereby critical issues impact each other, today’s businesses and insurers can no longer look at challenges in isolation one issue at a time. A holistic, collaborative and integrated approach to minimizing risk and improving outcomes is called for instead.

Aging Infrastructure, Aging Personnel


Robert Rokicki, Senior Vice President, Liberty International Underwriters

The irony of the domestic energy surge is that just as the industry is poised to capitalize on the bonanza, its infrastructure is in serious need of improvement. Ten years ago, the domestic refining industry was declining, with much of the industry moving overseas. That decline was exacerbated by the Great Recession, meaning even less investment went into the domestic energy infrastructure, which is now facing a sudden upsurge in the volume of gas and oil it’s being called on to handle and process.

“We are in a renaissance for energy’s midstream and downstream business leading us to a critical point that no one predicted,” Rokicki said. “Plants that were once stranded assets have become diamonds based on their location. Plus, there was not a lot of new talent coming into the industry during that fallow period.”

In fact, according to a 2014 Manpower Inc. study, an aging workforce along with a lack of new talent and skills coming in is one of the largest threats facing the energy sector today. Other estimates show that during the next decade, approximately 50 percent of those working in the energy industry will be retiring. “So risk managers can now add concerns about an aging workforce to concerns about the aging infrastructure,” he said.

Increasing Frequency of Severity

SponsoredContent_LIUCurrent financial factors have also contributed to a marked increase in frequency of severity losses in both the midstream and downstream energy sector. The costs associated with upgrades, debottlenecking and replacement of equipment, have increased significantly,” Rokicki said. For example, a small loss 10 years ago in the $1 million to $5 million ranges, is now increasing rapidly and could readily develop into a $20 million to $30 million loss.

Man-made disasters, such as fires and explosions that are linked to aging infrastructure and the decrease in experienced staff due to the aging workforce, play a big part. The location of energy midstream and downstream facilities has added to the underwriting risk.

“When you look at energy plants, they tend to be located around rivers, near ports, or near a harbor. These assets are susceptible to flood and storm surge exposure from a natural catastrophe standpoint. We are seeing greater concentrations of assets located in areas that are highly exposed to natural catastrophe perils,” Rokicki explained.

“A hurricane thirty years ago would affect fewer installations then a storm does today. This increases aggregation and the magnitude for potential loss.”

Buyer Beware

On its own, the domestic energy bonanza presents complex risk management challenges.

However, gradual changes to insurance coverage for both midstream and downstream energy have complicated the situation further. Broadening coverage over the decades by downstream energy carriers has led to greater uncertainty in adjusting claims.

A combination of the downturn in domestic energy production, the recession and soft insurance market cycles meant greatly increased competition from carriers and resulted in the writing of untested policy language.


In effect, the industry went from an environment of tested policy language and structure to vague and ambiguous policy language.

Keep in mind that no one carrier has the capacity to underwrite a $3 billion oil refinery. Each insurance program has many carriers that subscribe and share the risk, with each carrier potentially participating on differential terms.

“Achieving clarity in the policy language is getting very complicated and potentially detrimental,” Rokicki said.

Back to Basics

SponsoredContent_LIUHas the time come for a reset?

Rokicki proposes getting back to basics with both midstream and downstream energy risk management and risk transfer.

He recommends that the insured, the broker, and the carrier’s underwriter, engineer and claims executive sit down and make sure they are all on the same page about coverage terms and conditions.

It’s something the industry used to do and got away from, but needs to get back to.

“Having a claims person involved with policy wording before a loss is of the utmost importance,” Rokicki said, “because that claims executive can best explain to the insured what they can expect from policy coverage prior to any loss, eliminating the frustration of interpreting today’s policy wording.”

As well, having an engineer and underwriter working on the team with dual accountability and responsibility can be invaluable, often leading to innovative coverage solutions for clients as a result of close collaboration.

According to Rokicki, the best time to have this collaborative discussion is at the mid-point in a policy year. For a property policy that runs from July 1 through June 30, for example, the meeting should happen in December or January. If underwriters try to discuss policy-wording concerns during the renewal period on their own, the process tends to get overshadowed by the negotiations centered around premiums.

After a loss occurs is not the best time to find out everyone was thinking differently about the coverage,” he said.

Changes in both the energy and insurance markets require a new approach to minimizing risk. A more holistic, less siloed approach is called for in today’s climate. Carriers need to conduct more complex analysis across multiple measures and have in-depth conversations with brokers and insureds to create a better understanding and collectively develop the best solutions. LIU’s integrated business approach utilizing underwriters, engineers and claims executives provides a solid platform for realizing success in this new and ever-changing energy environment.



This article was produced by the R&I Brand Studio, a unit of the advertising department of Risk & Insurance, in collaboration with Liberty International Underwriters. The editorial staff of Risk & Insurance had no role in its preparation.

LIU is part of the Global Specialty Division of Liberty Mutual Insurance.
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