Injury Claims and UR: A Love-Hate Relationship

April 23, 2019 Brent MacLean

 

“Onerous.” “Too slow.” “Adversarial.”

Why does everyone seem to hate utilization review? 

Utilization review for workers compensation and auto injury claims has two goals:  to improve the quality of medical care and to reduce unnecessary cost.

UR is at its best when it ensures safe and expedient care, while preventing excessive costs and waste. But the current process is universally disliked. Providers resent being told how to practice medicine. Payers dislike being the scapegoat when care decisions are denied. And patients and their families – as well as their employers – are made to feel like pawns between the two. 

These problems stem from outdated technology and an operating model that has essentially unchanged in over 40 years.

Bringing UR into the digital era

So how do we modernize UR to ensure its effectiveness from the perspective of all stakeholders? Let’s start by asking what if.

Today UR is very arbitrated and transactional. What if it was a medical management intervention instead, viewed as an opportunity rather than a check off a to-do list?

One of the biggest criticisms of UR is that it slows down access to medical treatment. What if UR could accelerate the delivery of quality care?

Physicians find the UR process deprives them of autonomy and say it’s an administrative burden. What if UR was transformed into a benefit – a way to adopt technology and embrace interoperability while increasing the quality of patient care?

To be truly effective, UR decisions must be collaborative. That’s why a key first step starts with joining utilization review organizations and treating providers in an efficient, evidence based medicine decision-making process that is erected on an integrated automation platform designed for speed and scale. 

Collaborative and connected

By bringing all UR stakeholders together in a process continuum, decision making is optimized. Intelligent automation has the power to make this possible.

For example, our new solution design for Stratacare® Utilization Review uses auto-adjudication technology to automate the application of state-appropriate treatment guidelines to requests for treatment, or requests for authorization. 

This up-front tool allows for instant decisions to facilitate the right review at the right time.  Three outcomes are possible: approval, registered nurse review, and peer review.  An approval outcome means that within hours the requestor can receive treatment certification, enabling the claim process to move forward. If an automated decision cannot be made, a Level 1 review by a UR nurse is initiated. The third outcome transfers the request directly to a level 2 review by a clinical peer review physician for a peer-to-peer conversation.

Whether they are working directly in our platform or receiving their work via secure electronic information interchange, peer reviewers evaluate a single source of the request. When the clinical peer review is complete, the data loads directly into Stratacare Utilization Review for streamlined processing and data analytics. 

Once in the Strataware medical bill review application, the data is mapped into coding families that include companion codes. This enables the bill review engine to identify and apply Stratacare Utilization Review decisions to all request-related medical bills. 

By effectively applying approvals to bills within Strataware, providers who treat within state guidelines see expedited payment.  Likewise, directly applying non-certification results in bill review delivers operational savings by denying charges related to unapproved care. And by providing an immediate automated notification back to the provider, the communication loop is closed on the episode of care.

To read more about our UR approach to accelerate quality medical care, check out this solution brief. Have questions or want to discuss your workers compensation or auto casualty claims program? Visit Conduent in Booth 817 at RIMS 2019, or drop me a note at medclaims-solutions@conduent.com.  

 

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Brochure - Stratacare Utilization Review

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