What is a Utilization Review?
It is the process of reviewing a treating physicians’ recommendations for medical treatment and services of a workers’ compensation injury including assessment of proposed treatment plan, duration of care, scope of services, specific injury and other patient factors. The purpose of the review is to monitor the quality and effectiveness of care and make sure it is exactly what the injured worker needs. Essentially, the Utilization Review ensures that all recommendations are reviewed by nurse case managers in workers comp who have the medical knowledge to determine if a medical treatment should proceed, delayed or rejected and replaced by another more effective method of care. Injured workers will receive an official correspondence from the nurse case manager that explicitly details whether or not the request for treatment or care has been authorized.
Importance of Pre-Certification for a Utilization Review
One very critical factor in the Utilization Review process in a workers comp claim is the pre-certification process for medical treatment before it is rendered and paid for. Pre-certification determines if the medical service, procedure or treatment is necessary and is either pre-approved or denied. The pre-certification and Utilization Review are both conducted by registered professional nurse case managers whose job is to determine that the treatments and procedures are aligned with the injury, appropriate and medically required. If the treatment recommendation or plan is denied, then the best alternative options for injured worker’s care are identified for swift recovery and return to work. The whole process of pre-certification and Utilization Review for workers comp allows for early detection of mismanagement of claims and treatment recommendations. This will help prevent unnecessary medical care that will increase the potential of additional costs and delays in the injured worker’s recovery.
Effective Utilization Review Management
In order to achieve improved outcomes and rapid recoveries for injured workers while reducing treatment costs and other medical expenses, it is important for employers to choose a medical management company that provides effective Utilization Review services. Novare’s utilization management program ensures the delivery of appropriate, clinically-sound care at the right time through medical treatment decisions that are consistent with evidence-based practice. Our team of nurse case managers for workers comp and licensed health care professionals are committed to providing optimal, cost-effective medical outcomes.
Novare is URAC Accredited – Workers’ Compensation Utilization Management, which demonstrates the organization’s commitment to quality, nationally recognized guidelines and evidence-based medicine. We have a national coverage process that includes credentialed, board-certified clinical reviewers.
Let us help your workers get the care they need. Call us at 866.532.1929 today.