UR Nation, Pt 1: 5 Principles of Effective Utilization Review

| | Utilization Review

Original article can be found on Work Comp Wire. In the 1980s, medical costs associated with workers’ compensation claims in Texas were among the highest in the nation, and rising. The state brought in several processes to put the brakes on this spending, including utilization review (UR). Still, costs continued to soar, and the administrative demands placed on both payors and providers were cumbersome and frustrating. A series of reforms tackled the challenges, in a bid to clarify the processes and tighten spending, particularly on high-volume, low-cost procedures such as physical therapy and diagnostic tests. The lesson of Texas suggests there are 5 principles that need to be in place for UR to be effective:
  1. It must be mandatory.
  2. It must be enforceable.
  3. It requires evidence-based guidelines.
  4. Medical professional must make medical decisions, not administrators or judges.
  5. Payors and providers must equally shoulder the administrative burdens.
These are the lessons of the Texas experience, but that experience has provided insights and ideas that can – and should – be applied nationwide as UR best practices.
For more thinking on the Texas experience, please see my article on workcompwire.com

Lisa Hannusch

Lisa Hannusch is CEO of UniMed Direct and founder of UR Nation. With experience in virtually every aspect of workers' compensation medical management, she is a nationally recognized authority on effectively managing utilization and medical claim issues. Lisa has direct experience as a healthcare provider, has conducted healthcare fraud investigations leading to prosecution, designed claims and medical software applications, and has worked as an insurance regulator and state agency rule and guideline author. She was an influential leader for requiring evidence-based medical determinations. At UniMed Direct, Lisa has built an industry leading managed care company specializing in ReviewStat – a leader in hosted medical management software, supported with services for UR and a national independent Peer Review Panel.

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