HSA’s first annual Survey on Utilization Review in Workers Compensation. is underway and we’ve got a few preliminary findings to report. (click on the link to fill out the survey)
We are surveying C level execs as well as desk-level folks (claims adjusters, claims execs) for their opinions concerning and results of UR; 80 responses so far and here are a few of the highlights.
– The vast majority of respondents utilize UM/UR to control medical costs and ensure appropriate medical treatment, while for a minority it is a revenue generator.
– Among desk-level respondents whose firms internalize UM/UR, over a third cite UM as a core competency as a key reason for performing UR in-house. 40% cite controlling UM costs, while almost half note UM is integrated with other medical management programs. This is in contrast to executives’ responses; only one in five claims UM is a core competency…
– There’s a big gap between desk level folks and execs when it comes to integration of UM with other systems, with execs twice as likely as front-line staff to report they are integrated. Interestingly, this is similar to the difference between execs and desk level staff we found in our bill review survey; most execs thought BR was integrated with UR but most desk folks did not.
There’s lots more to come, as we’re collecting a wealth of data on utilization review trends, services, vendors, costs, outcomes, and functions. Respondents receive a detailed version of the survey report; the public version is limited to highlights and major findings.
We welcome your participation in the survey. The On-Line Survey should take 20-25 minutes tops, and one lucky recipient will receive an iPad 2 as a token of our appreciation (make sure you include your contact info if you want a shot at the iPad).
Jun
12
Utilization Review is a tool, if managed correctly by experts can perform as designated to ensure quality and focus on appropriate care. I believe that the rules need to allow comments to the requesting provider if care is can be enhanced by suggestion. The patient SHOULD be included in the treatment considerations.
Poor information, inadequate computer systems and lack of coordination between key UR players are some of the key reasons industry experts estimate that 20% to 25% of workers’ comp medical spending is unnecessary.
For UR to be effective, the claims examiner, UR nurse, peer review physician, bill reviewer and (if applicable) case manager all need to share the medical history and coordinate their activities. Too often, the URO or in house UR nurse does not have easy access to prior authorizations made by claims examiner or to prior bill review payments; the bill reviewer has to search through a jumble of previous bills, claims notes and input from the UR team to determine whether the treatment was authorized, denied, or exceeded limits; the claims examiner has to click through information from multiple databases in different formats to make a decision.
These coordination problems result in a significant portion of the excess medical payments.
I’ll be interested in seeing your report. A follow up report with the same/similar questions ask of Physicians and their staff might also be enlightening.