What Is Appropriate Care in a Work Injury Claim?
Helping an injured employee safely return to work and normal life activities should be a goal of every employer during a workers’ compensation claim. Accomplishing this goal requires timely, high-quality medical care. But it’s not uncommon for appropriateness of care to be questioned during a workers’ compensation claim. Appropriateness of care can be influenced by several factors, such as extent of injury, stakeholder satisfaction, desired outcomes, or even care options. And because the care management aspect of a work injury claim ties into everything from employee recovery to overall claims cost, it’s pivotal for employers and insurance carriers to partner with a care provider who understands the workers’ compensation system, the importance of return-to-work programs, and the financial impact both can have on an employer’s bottom line.
Managing a work injury claim can come with its challenges; even the largest and most resourceful companies can struggle to navigate the rules of the oft convoluted workers’ compensation process. With rising medical costs and ongoing regulatory compliance challenges, efficient work injury claims management must be a business priority regardless of company size, industry, or available resources. From medically unnecessary treatments to the overprescribing of opioids, determining appropriate care in a work injury claim may require an employer or insurer to solicit an unbiased expert medical opinion. For this reason, the utilization review (UR) process has become a pivotal component of the workers’ compensation system. In fact, a utilization review for a workers’ compensation claim is mandated in many states and jurisdictions.1
Workers’ compensation utilization reviews
A utilization review is a process of validating the medical necessity of requested medical services against evidenced-based treatment guidelines in a work injury claim. This review of work injury claims helps to mitigate instances of misuse or overutilization of authorized medical services.
A UR service provider may operate as a part of a third-party administrator who evaluates work injury treatment requests in the interest of establishing medical necessity of the requested services. Many UR agencies are accredited by URAC® and staffed by licensed medical professionals who utilize rigorous URAC standards to consult and conduct medical reviews on work injury cases.2 Having the URAC accreditation is a distinction that represents a high level of commitment to providing high-quality care to patients.
There are different types of workers’ compensation utilization reviews, which include1:
- Prospective: Review of medical necessity conducted before the services are performed
- Concurrent: Review of medical necessity and continuation of care conducted while an injured employee is receiving medical services
- Retrospective: Review of medical necessity conducted after the delivery of medical services
- Reconsideration: Review following the initial denial of medical services
- Appeal: Review following the denial of an initial review and/or reconsideration
The role of the utilization review process
According to a guidance statement from the American College of Occupational and Environmental Medicine (ACOEM), the utilization review process is intended to work in concert with stakeholders during a workers’ compensation claim. During this collaborative process, medical services that are eligible for reimbursement are compared to evidence-based treatment guidelines to assure that injured employees receive high-quality care that is both necessary and devoid of inefficient, potentially harmful, and insignificant care.1 ACOEM further states that the UR process looks exclusively at the medical necessity of a request for medical services in a work injury case rather than issues pertaining to causation or claims compensability.1
A utilization review for a workers’ compensation injury will typically involve a licensed medical professional, such as a registered nurse (RN), who determines if the treating physician’s choice of medical treatment coincides with the injury and applicable treatment guidelines. If approved, the treating physician performs the recommended medical service. But if the requested medical service cannot be approved by the nurse and there are questions about the plan of care, a peer review ensues.
“Utilization review organizations typically use physician or peer review services when requested medical services are not congruent with recognized evidence-based practice guidelines,” explained Michael Southwick, Concentra® assistant vice president of Medical Advisory Services and Medical ReviewStream™. “Typically, the utilization review nurse has reached a point in the medical necessity review of the submitted clinical information where initial and/or continued certification fails to meet the appropriate guidelines. At this point, the UR nurse refers the case to a physician or peer, or another appropriate provider for analysis and a medical necessity recommendation.”
Selecting a utilization review services provider
There are several factors a business should consider when selecting a utilization review services partner. Let’s look at three elements that help define the approach a UR provider should take to determine care appropriateness in a workers’ compensation claim:
- Focus on outcomes. While driving down medical costs is always top of mind, it shouldn’t overshadow the goal of delivering quality care that promotes recovery along with a good patient experience. The UR provider should have the expertise to administer services that can help reduce costs without compromising care (or denying the appropriate care) or failing to meet compliance standards.
- Evidence-based guidelines. As a best practice, a workers’ compensation UR provider should follow statistically backed results to assess the level of treatment. In other words, a peer reviewer should compare treatment in a work injury claim to jurisdictionally mandated treatment guidelines and/or nationally recognized evidence-based guidelines to ensure treatment is medically necessary.
- Timely decision-making. Understanding the need to expedite appropriate care is essential to improving health outcomes and managing costs. But making timely UR decisions requires a service provider to possess a track record of achieving good outcomes using strong diagnostic skills and a reliable workflow that promotes clear communication with all stakeholders throughout the case duration.
Concentra offers an evidence-driven approach to workers’ compensation claims management through Medical ReviewStream, a URAC-accredited organization with a nationwide network of board-certified clinicians who deliver expert medical review services. From medical expert opinions and physician peer reviews to drug utilization services, Medical ReviewStream helps organizations overcome the medical and administrative challenges that can occur during a workers’ compensation claim. And according to Southwick, this is accomplished by delivering peer review services that are customer-centric, streamlined, and cost-conscious.
Medical ReviewStream provides more efficiency and also frees up the time utilization review organizations might otherwise need to invest,” explained Southwick. “We provide customized cost-mitigation strategies and services through a large, nationwide network of peer reviewers. When a customer uses Medical ReviewStream, they no longer have to worry about recruiting, contracting, training, and quality assurance of their peer reviewers. All of these things are part of our services.”
Maximizing the return on investment and ensuring medically appropriate treatment is rendered are central to every utilization review process during a workers’ compensation claim, and so is maintaining compliance with statewide workers’ compensation regulations. Businesses rely on peer review services like Medical ReviewStream to better understand state and federal guidelines and to help expedite treatment for faster, sustainable recovery.
"Medical ReviewStream is an attractive option for employers who occasionally need expertise to understand medical documentation in utilization review and workers’ compensation claims adjustment,” said Southwick.
Timely, appropriate care with greater financial control
Because overutilization of medical services can drive up the costs associated with a workers’ compensation claim, it’s important to create a safe balance between proactively managing the medical aspects of a claim and ensuring proper and timely care is rendered to injured employees. Medical ReviewStream can complement a company’s utilization review operations and claims management process to mitigate rising injury costs and overcome regulatory compliance challenges. To learn more about Medical ReviewStream and its utilization review and clinical peer review services.
- Utilization Review in Workers’ Compensation - ACOEM. ACOEM Guidance Statement. (n.d.). Retrieved from.
- Accreditation FAQs. Utilization Review Accreditation Commission. (2022, January 14). Retrieved from.