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By PETER ROUSMANIERE, an expert on the workers' compensation industry

A doctor, physical therapist or other clinician wants to treat the patient in a certain manner. The clinician asks the workers' compensation claims-payer for permission to treat, and the payer returns with a response. If the payer approves, which in practice is usually the case, treatment goes ahead.

Nowadays, according to experts with a payer perspective, UR, as it is ubiquitously called in the industry, better be lean and streamlined to be worth the expense to the payer and inconvenience to the provider.

Anita Weir, who directs managed care for Safeway, the large grocery chain, found great value, for instance, in getting her UR and her medical-bill-review systems to work together smoothly. Outside her provider network, she found a disturbing high share of medical bills to be rejected.

"Twenty percent of medical bills of what a bill-review company reviews should not be paid because precertification was not requested or the bill failed to match the approval," she said.

Michael Kelley, vice president of claims for AIM Mutual Insurance Cos. a New England regional insurer, keeps his enthusiasm for UR well under control.

"Why do I need," he asked," to do UR on the finest orthopedic surgeons at Massachusetts General Hospital?"

Kelley noted that, in Massachusetts, UR "was a very good thing" at first.

"It forced the payers to pay attention to what they were paying for," he said. "It also forced us to issue denials on a timely basis. Over time, the provider community got used to the system, and most submissions were just rubberstamped as approved.

"The problem is the cost to administer the process has not declined," he added.

Upward of half of all UR requests can be managed entirely by automation, out of expensive human hands, resulting in less bureaucracy and delays to the providers. This is according to James Schlueter, president of Effective Health Systems. For some years Schlueter has developed computer products that put UR requests into a computer-driven workflow.

Full-scale UR need only be ordered for 30 percent of treatment plans, Schlueter estimated, with the remaining 70 percent being either completely or partially automated. Also, providers should be able to inquire online in advance to predict approval.

Betsy Robinson, senior vice president for product development for Coventry Workers' Comp Services, sets a lower figure for automated review: only 30 percent.

Robinson, however, is ready to flip utilization review from a front-end approval to a retrospective evaluation tool. This redeployment, she said, can work when the payer is using a network of carefully chosen providers. The back-end review can then make sure their best-practice patterns remain intact.

Her strategy involves a subtle but important shift in thinking about what UR is. Most claims payers view UR as a cost containment tool, eliminating unnecessary care. Robinson sees UR more as positive tool to support adherence to best practice.

UR review draws from treatment guidelines, which especially over the past decade have been officially endorsed or become de facto points of reference in most states. Kelley, Schlueter and Robinson agree that some times treatment that otherwise might not obtain a UR approval should be done. An example is where co-morbid conditions of the injured worker call for an unusual treatment plan.

Then again, providers keep on hatching questionable treatment ideas. And some states, UR carries less and less weight. Workers' compensation judges in the Bay State have told defense lawyers they don't want to hear disputes over approval for medical care, Kelley said. Payers in Massachusetts are almost certainly going to pay for treatment if the injured worker (that is, her attorney) seeks to overturn a UR denial.

So it appears that, today, utilization review makes sense if it exerts an efficient sentinel effect to discourage these notions, pinpoints full-scale reviews and connects with medical bill review.

June 16, 2011

Copyright 2011© LRP Publications