Medical ReviewStream by Concentra Focuses on Quality Care, Efficiency
Quality and appropriateness of medical care
Depending on the type and severity of an injury, medical expenses can represent anywhere from 48 to 66 percent of a workers’ compensation claim, with indemnity costs accounting for the remainder.1 Medical management helps ensure the quality and appropriateness of care as a means of controlling medical expenses, while also helping to ensure an injured employee receives the quality care needed to deliver the desired medical outcome. When there are red flags, such as treatment departing from medical guidelines or appearing to be excessive – an option is to refer the case for utilization review, which can be done prospectively, concurrently, or even after treatment has been provided.2 Government payors, private insurers, health maintenance organizations, and self-insured employers use utilization review.
Medical ReviewStream by Concentra® provides physician advisors to review medical treatment and services to complement utilization review operations and claims handling and adjustment. The main focus of a medical opinion issued by the physician advisor is one of medical necessity. Based on state-mandated treatment guidelines, the physician advisor analyzes the requested medical services to determine if they are medically necessary based on (1) the information provided with the request, (2) certain other information obtained through peer-to-peer discussions, and (3) their own medical judgment when circumstances are beyond the scope of treatment guidelines. The doctor conducting utilization review does not recommend care but only renders an opinion on whether proposed or provided care is appropriate. This opinion that can affect insurance coverage decisions.
Choose advisory services with prestigious backing
There are a variety of circumstances when a utilization review operator would need a medical opinion – as additional input for initial peer reviews, workers’ compensation case reconsiderations or appeals, medical necessity determinations outside the utilization review process, as a single source of peer review, and to augment their own staff advisors reviews and appeals with the help of state-licensed advisors. Medical ReviewStream by Concentra fulfills all these needs, as well as providing staffing assistance through medical directorship services for utilization review clients.
Medical ReviewStream is backed by Concentra and its parent company, Select Medical. In deciding on physician advisor services for utilization review, the backing of a large organization can offer benefits that may not be available from a standalone single-physician service, such as:
- A deeper well of clinical knowledge and experience
- Greater efficiency in compliance due to expertise with the many states’ wide range of requirements and deadlines
- Established communication and reporting systems that quickly and efficiently collect and assimilate data and evidence-based criteria used in developing medical opinions
- Technology including electronic data interchange interfaces that streamline utilization review
- Reduced utilization review costs as a result of these added efficiencies, saving time and money
Greater efficiency and getting your time back
“Medical ReviewStream provides more efficiency and also frees up the time utilization review organizations might otherwise need to invest. We provide a larger, nationwide network of quality physicians and conduct all recruiting, contracting, training, and quality assurance needed. That’s a significant time savings, as well as peace of mind, for utilization review organizations, says Mike Southwick, assistant vice president of Medical Advisory Services and Medical ReviewStream.
Medical ReviewStream also provides medical opinions for claims in consideration of compliance with the Americans with Disabilities Act (ADA), the Family and Medical Leave Act (FMLA), and state workers’ compensation laws.
A high-stakes decision for medical practice today
“Utilization review has become an integral part of medical practice, has influenced medical care within the workers’ compensation system, and is mandated in several states and jurisdictions” and has “significant implications for health care choices, outcomes, cost of care, and stakeholder satisfaction,” according to the ACOEM Guidance Statement on Utilization Review in Workers’ Compensation.
“Utilization review is intended to be a collaborative process in which proposals to perform medical service for reimbursement are compared with high-quality, evidence-based guidelines for the purpose of assuring that patients receive the appropriate care necessary while avoiding ineffective, potentially harmful, and low-value care, by looking solely at the medical necessity of a request and not at the issues surrounding compensability or causation,” the statement says. Thus, utilization review is a benefit to all stakeholders, including injured employees, as a way of avoiding unnecessary treatment.3
Another value of the utilization review process is that not all treating physicians are on the same page in their implementation of new evidence-based medical treatment plans and may continue to use historic treatments that have since been proven ineffective. Utilization review identifies those instances to help protect patients and collaboratively help treating physicians to learn new evidence-based treatment approaches.4
These purposes are all well-served by the Concentra and Select Medical backing of Medical ReviewStream and their networks of physicians grounded in the latest evidence-based medical treatments.
NOTES
- Workers’ Compensation Costs. National Safety Council. Injury Facts.
- “Back to Basics: Cost Control and the Role of Precertification and Utilization Review in Workers’ Compensation.” June 11, 2018. MPower.
- Bean M, Erdil M, Blink R, McKinney D, Seidner A, and the ACOEM Utilization Review Task Force. Utilization Review in Workers’ Compensation. Journal of Occupational and Environmental Medicine. 2020; 62(6): e274-e286.
- Bean M, Erdil M, Blink R, McKinney D, Seidner A, and the ACOEM Utilization Review Task Force. Utilization Review in Workers’ Compensation. Journal of Occupational and Environmental Medicine. 2020; 62(6): e274-e286.
