Yesterday’s post about Mass General’s mishandling (to be kind) of a woman’s procedure and reimbursement thereof elicited a thoughtful email from the former CEO of a major work comp insurer.
Here’s what he said (identifying details removed to protect the source).
I got in trouble early on with (the payer’s) UR staff and attorneys because (after giving them multiple direct orders to clean up pre-auth letters) I began directing them to pay for procedures they approved but later wanted to deny. They would simply say that the procedure was appropriate for the injury but NEVER check the claim to see if it was part of the approved injury. For instance, they would approve a shoulder surgery as medically appropriate but the injury was for a knee. Had they checked the claim they would have seen the shoulder was not covered. Regardless, the UR folks approved it in pre-auth and the surgery was done.
Only afterwards, when the bill came in and the claims rep denied it did UR look at the claim more closely and support the adjuster. UR’s excuse was that in very small lettering at the bottom of the page it said that we (the payer) may not be liable if blah blah blah. I told them that was execrable and to clean up the process and language. For too long, the UR department did not and so I made them pay the claims and docked them in their evaluations.
If the doc and the patient did everything they were supposed to and got an OK in writing I felt it was the carrier’s ethical and moral responsibility to pay regardless of what the lawyers said.
Hear hear.
I’m of the opinion that this happens more frequently than one might surmise, but these types of determinations are kept quiet so as to not motivate more requests for treatment on non-covered body parts/conditions.
I’d also surmise that many non-approved treatments get paid due to the lack of an automated electronic connection between UR and bill review/claims. This is also an ethical issue of high importance, as it is a failure to act as a responsible fiduciary.
What does this mean for you?
How does your company handle these issues, and how do you feel about that?
Jun
22
Joe,
The UR companies completing precerts are not responsible for determining causation with requests for procedures – meaning they are not to check whether the body part is compensable; that is the role of the adjuster / employer. It should have never been sent to precert – but once the UR ofc receives a precert, they only comment on medical necessity. How would the UR /Precert company have checked this claim in this instance? They don’t have access to the claim information, just the request to precert a particular procedure.
Rather unfortunately, particularly in workers’ comp, it’s often a direct cause of state regulators who craft regs in such a way that they mandate UR of all requests whether compensable or not because regulators are clueless to the real work of claims adjusting and medical management. So UR does the review of medical necessity of a procedure – it may be medically necessary, but unrelated so they include such a note in the letter. UR is not approving payment, they’re reviewing medical necessity. States often mandate this.
E.g. TX Rule 134.600 (http://info.sos.state.tx.us/pls/pub/readtac$ext.tacpage?sl=R&app=9&p_dir=&p_rloc=&p_tloc=&p_ploc=&pg=1&p_tac=&ti=28&pt=2&ch=134&rl=600)
mandates utilization review of all requests whether compensable or not but if it’s not compensable, the UR letter must include a note to this effect. Even if treatment is determined to be medically necessary, 134.600 [d) “The carrier is not liable under subsection (c)(1)(B) or (C) of this section if there has been a final adjudication that the injury is not compensable or that the health care was provided for a condition unrelated to the compensable injury.” )
Same thing for California Rule 9792.6 et seq. (See UR FAQs under UR and Causation: http://www.dir.ca.gov/dwc/UtilizationReview/UR_FAQ.htm#10)
Hospitals have their financial counselors (as referenced in yesterday’s post) who say one thing one day, then may say something completely different the next (as well as when billing patients.) There is nothing transparent about hospital billing except perhaps the unfortunate prevalence of fraud.)
This issue can happen in the work comp field or when managing a case from a health & welfare persepctive. The key is Integration. At CoreSource UM/CM & Claims are interconnected – we send a nightly extract to claims stating what was preauthorized/denied/pended etc. Furthermore, we KNOW that some services may be medically necessary but are not Covered! That’s why we confirm that there are benefits (Coverage) for certain procedures/surgeries before we precertify them. Claims & Medical Management must be integrated or you are asking…no begging for trouble!
It sounds like “former CEO” has a misconception how the workflow from the claims office to the UR vendor works. In many cases the UR Company is a vendor to the claims operation and often does not have access to the claims system. The adjuster is the initial gatekeeper of the treatment requests and typically makes the determination as to what should go to UR. If the treatment request was for a denied body part, then why would they send it to the UR vendor? Not to mention if the adjusters are not reviewing the treatment requests before sending then the UR Company is going to be reviewing EVERY treatment requests that comes in. That overuse of UR could become a cost driver too, where most TPA/Insurers will have a threshold in place for what they send to UR. Lastly, in CA we have case law (en banc Decision Lisa Simmons) that states UR can NOT deny a request based on compensability, they can only bring up the issue and then the decision must go back to a panel QME to determine compensability.
UR is about reviewing treatment requests for medical necessity and helping to ensure treatment is in accordance with evidence based medicine. If you are having issues with non-compensable body parts being sent to UR, maybe someone needs to look at who is sending them.
All – the former CEO has a very good understanding of the UR process. UR at his former company is internal and is not vended out to an outside firm.
There are many different paths that a UR request can take; in this situation the request comes into the medical management dept and not via the adjuster. This is done to expedite the UR process and reduce delays that could hamper treatment and RTW, and fall afoul of statutory requirements.
As noted in the post, the exec had requested the UR department ascertain body part etc before conducting any pre-certs; their failure to do so drove the problem described in the post.
Paduda
Requests should not be sent on unaccepted body parts. CA regs are very specific that if treatment is approved, it will be paid for. We no longer have a disclaimer on our letters regarding UR is only to determine medical necessity, not compensabiliy.
We are very specific to our clients about not sending us treatment requests on non-acccepted body parts, the regs do not require that all requests go to UR.
We don’t want to buy any body parts for our clients because we can only determine medical necessity, not relatedness to the injury. A shoulder case that has a request for open heart surgery with a mitral valve prolapse may fit guidelines for treatment and we would have to approve. Oops, now the carrier owns the heart as well.
Unfortunately, this scenario and the many contributing factors are all too common in Work Comp. In some cases we should also not discount complicity by providers who want reimbursement when there is no group health insurance.