What is the Role of Utilization Review in Workers’ Compensation?

By February 8, 2021 No Comments
Role of Utilization Review in Workers Compensation

According to the National Safety Council, the total cost for work injuries in the United States in the year 2018 was $170.8 billion, and more than 50% of this amount is spent on medical and administrative expenses for injured workers.As we all know, workers’ compensation is the primary source of compensation for lost wages and medical expenses in relation to work-related injuries and illnesses, and medical care is its most important component. 

Despite efforts by the government and the business sector to enforce safety in the workplace, the medical costs due to workplace injuries are rising even higher and are expected to rise in the coming years.

While the cost of medical treatment is a normal consequence of workplace injuries, expenses unrelated to the worker’s injury could be added to the cost. It is one of the contributing factors to the rise of medical treatment cost of injured workers. 

There are instances when unnecessary medical treatment is administered to treat an injury. For this reason, the need to prevent medical treatment that is not related to work-related injuries became necessary. It is called workers comp utilization review

What Is Workers’ Comp Utilization Review?

Utilization review workers’ compensation patients typically go through is the process of assessing medical services for the purpose of evaluating the appropriateness and quality of the care provided to an injured worker. It is intended to review and assess the most important services proposed or delivered by a medical care provider. These are:

  • The treatment plan
  • The duration of care
  • The scope of services
  • The injury, and
  • Other factors relevant to the effectiveness of the medical care services

There are three types of utilization review in workers’ compensation claims. These are:

  1. Prospective Review – This is the most common type of review. It is done before a service is performed.
  2. Concurrent Review – This is a review that is done during the course of the treatment.
  3. Retrospective Review – This is a review that is performed after the medical services have been provided.

What is Precertification Process for Treatment?

Precertification is a component of the utilization review process. It is used to determine the necessity of medical treatment or services to be administered to an injured employee. Carriers of workers’ compensation insurance use the outcome of this determination as the basis to pre-approve or deny treatments or medical procedures before these are rendered or even paid for.

A precertification however, is not always required each time an injured worker visits the treating physician. It is needed only when the treating physician determines that the injured employee needs a medical treatment or procedure that is not routinely included in the patient’s visit to the doctor’s office. (Ex. non-emergency hospital admittance, non-emergency surgical procedures, etc.)

Normally, utilization review and precertification are both performed by a clinical professional such as a registered nurse. If the nurse sees that the medical treatment is appropriate and necessary based on results of diagnostic tests, clinical evaluation, and other reports, he/she will notify the treating physician of its validity and the treatment can be administered.

Precertification and utilization review are tools employers and workers’ comp carriers can use to detect issues and red flags surrounding a workers’ comp claim. It helps them determine treatments that provide real value to employers and provide a positive effect on the patient. These two processes ultimately work to reduce costs because of their ability to prevent unnecessary and prolonged medical treatment of an injured worker.

The Benefits of Utilization Review

Utilization review and precertification are basically designed to determine unnecessary medical services that must be eliminated. These are processes that work to make sure that the injured worker filing the workers’ comp claim receives quality, appropriate and necessary medical care. However, it does offer other important elements that are beneficial not only to the injured worker, but the employer and the medical provider as well.

Benefits of Utilization Review to Patients

  • Reduces the patent’s length of stay in the hospital
  • Improves the quality of care
  • Facilitates easier and simpler discharge planning process 

Benefits of Utilization Review to Payers / Employers

  • Reduced administration costs
  • Avoidance of fraud and abuse because of evidence-based care 

Benefits of Utilization Review to Medical Services Providers

  • Enhanced and consistent quality of care results in satisfied customers.
  • Pleasant customer experience leads to customer loyalty.
  • Reduced patient length of stay results in higher patient turnover and improved revenues.
  • Prudent use of resources ensures quality care. It results in early recovery of patients.
  • Tangible cost savings. It is a result of the medical providers’ adherence to evidenced-based clinical guidelines.  

As an employer, there are a lot of good reasons why you should consider using workers’ comp utilization review for your injured employees. It offers an assurance of appropriate, quality and medically necessary care that works to facilitate fast recovery. It can shorten your worker’s hospital length of stay, reduce their hospitalization cost and possibly bring them back to productivity in the earliest time possible.

Call Novare at (866) 532-1929 for an appointment. We’re always happy to serve you.

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