Utilization Management / Utilization Review (UM/UR) is an Effective Tool to Assure the Recovering Worker Receives the Most Appropriate Treatment, with a Goal of Return to Health and Function.

CompAlliance believes there is a difference between a proactive Utilization Management approach and a reactive Utilization Review approach when facilitating appropriate care. We believe when collaborating with providers you reduce the overall claims cost, by expediting the most appropriate treatment in order to facilitate recovery and Return to Work. Conversely, when a Utilization Review program is focused on denials, they often ADD to the cost of a claim by delaying recovery and adding friction to the claim.

5 Best Practices to Look for When Using a UM/UR Provider

  1. Is your UM/UR Provider Outcomes-Driven? If you request your vendor produce cost-savings and ROI data, you are creating a perverse incentive to deny care that may be necessary and appropriate for recovery. “Savings” on the medical side of the claim may drive up indemnity costs. Consider taking a holistic approach to Utilization Management instead. What treatment is necessary to expedite recovery and return to work? The charts below represent two Utilization Management clients. Both illustrate the outcomes-based approach to Utilization Management drives down claim costs and speeds return to work and MMI.
  2. Learn from your Data. Your UM vendor should be able to provide you with extensive data about your medical providers. Use that data and claims data to refine your MPN, to create prior-authorization protocols, and expedite appropriate medical care. Some of the questions to ask while evaluating this data:
  • Which providers are adhering to guidelines and have the highest approval ratings?
  • Which providers are cooperating with your return to work efforts? Returning recovering employees to work with the lowest number of lost days?
  • Which providers submit requests with reports that clearly support the need for treatment, versus those that require additional information to be submitted (which leads to delays and additional UM efforts)?
  • What categories of treatment are always approved?
  • What categories of treatment are problematic?
  • Where is unnecessary friction being created?

  1. Get to Yes, Quickly. Does your utilization management team understand the need to approve appropriate care as quickly as possible? Expediting appropriate care facilitates recovery and return to work and is much more cost-effective in the long run than delaying care through denials on technicalities or overly strict adherence to guidelines. Guidelines are developed on a bell-curve and not every recovering worker fits in that bell-curve. If there are compelling reasons to approve outside of guidelines, your UM vendor should do so.

If you have trusted medical providers who achieve good outcomes and have good diagnostic skills, and the recovering worker meets criteria for surgery, do you really need to make them have every confirmatory diagnostic test before you approve surgery to address the underlying issue? How much cost and delay does requiring scheduling of an MRI and getting the subsequent diagnostic confirmation add to each surgical request? Is your recovering worker losing time during this additional testing timeframe?

  1. Use Automation, Wisely. Automation of repetitive tasks, and automation to assure timeliness, are wonderful things. Automatically matching guidelines to a given request is also very efficient, but automating clinical decisions is not as easy as it sounds. If you are trying to achieve the most expedient recovery and return to work, automatically approving treatment has its pitfalls.

At many points in the recovery process, guidelines may support any number of treatment modalities, but it still takes clinical judgement to know which is the best course of treatment, at this TIME, for this RECOVERING WORKER, with these CO-MORBIDITIES. A Utilization Management program takes an approach which says, “what is the BEST course of treatment?”  First Level UM case managers are not able to deny treatment that is supported by guidelines, but the case manager can ask “could we try this…?” Most often, as reflected by the charts above, with great results.

  1. Know When to Say No. However, there are times when a denial of treatment is necessary. Co-morbidities may create a risk for the recovering worker, despite the fact they meet the clinical criteria for care. A diabetic with hypertension, may have meet criteria for a surgical repair of their shoulder, but are they fit for surgery? Drug interactions may pose harm to recovering workers when medications are taken together, or with certain supplements. In these cases, a denial should clearly delineate the risks to the recovering worker.

Not everyone is a good actor. We have seen the spinal hardware and toxicology schemes, the opioid crises, the compounding and topical medications that are inappropriately prescribed. These and other schemes create waste in the system, and further victimize the recovering worker in their worst forms.

In conclusion, when your UM/UR Vendor facilitates appropriate, timely care or puts a stop to inappropriate care, they are protecting the recovering worker, and ultimately that is the goal of good Utilization Management.

Also see:
Top Tips in Workers’ Compensation
FAQ about Workers’ Compensation