Utilization Review - Evaluating Your Program and Building Toward the Ideal

September 1, 2011

There are some common sense approaches to Utilization Review that can minimize the unintended consequences, and make your program both effective, and efficient. Suggestions include:

Tighten protocols to allow Adjusters to approve standard diagnostic tests and treatments. Allow early physical therapy treatments to ensure that injured workers get started on treatment immediately and have the benefits of immediacy of care.
Review your costs carefully to be sure you are paying competitive rates. Dig deep to understand what the rates really are, given the wide variances in how charges are applied (See # 2 above). And consider the following ....
Evaluate your medical networks to focus on Physicians who achieve the outcomes that make a difference. Select the "best" Physicians to be in the medical networks — defining "best" based on outcomes (including return to work).
Empower those "best" Physicians to gain the trust of their patients by eliminating the delays and second guessing that comes with requiring the Physician to wait for Utilization Review approval. This can be accomplished by reserving Utilization Review for very complex or non-standard procedures. This can reduce expenses dramatically by eliminating the Utilization Review costs for treatments and tests that are reasonable, necessary and prescribed by Physicians we have identified as the "best." You can then reserve Utilization Review (for those Physicians) for those types of procedures that may still benefit from a second look — i.e. surgeries, advanced rehab techniques, and non-standard therapies. Not only can empowering "best" Physicians reduce costs, but it may very well reduce the litigation and protracted claims outcomes that may actually begin when we unintentionally drive that wedge between the treating Physician and the Injured Worker.
Continually measure outcomes in order to reevaluate which physicians are deserving of exemption. Provided physicians with benchmarks of their outcomes (i.e. Return to work, etc.) in order to give them a means to compare their performance and earn "best" status.

Ultimately, if Injured Workers are treated only by the "best," perhaps Utilization Review would become unnecessary. Perhaps we would eliminate the built in delays that Utilization Review causes, eliminate the expense of unnecessary Utilization Reviews, and focus all our resources on the Physicians and treatments that are likely to result in recovery and return to work.

Judy Adlam

Judy Adlam is president and CEO of LWP Claims Solutions, an organization that leverages a culture of teamwork and excellence to consistently deliver results that are far superior to industry standards. She is a chartered property casualty underwriter (CPCU) and a senior claims law associate (AEI).