Checks and Balances in Utilization Review: Appeals and State Review Processes

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Client, patients, and requesting physicians sometimes disagree with utilization review (UR) decisions. For cases such as these, checks and balances, such as state and organizational review processes, are in place to ensure that patients receive the best treatment.

California and Texas: Two Examples of State Review Processes

Most states that regulate UR have government-based appeal processes in place. California, for example, uses a process called Independent Medical Review (IMR). Claimants or requesting physicians who believe decisions are inappropriate, can file IMR requests as outlined by the state rules. These requests go to a medical review agency that reviews the case and either upholds or overturns the decision.

Texas employs a slightly different state appeal process using Independent Review Organizations (IROs). Rules require that an appeal must first be filed timely with the UR provider, and the initial decision upheld, prior to requesting an IRO review through the Texas Department of Insurance. When a dissatisfied patient or physician files a request for an IRO review, the state passes the request to a certified IRO. The IRO reviews the case, upholds or overturns the initial decision, and defines the decision.

Both states have specific requirements regarding the procedures, contents and timeliness of requests.

Claimants and Physicians May Also Appeal to UR Organizations

When appealing directly to a UR organization, successful peer-to-peer conversation and documentation are key. Physicians need to include all the necessary and relevant clinical notes with their initial requests in order for reviewers to clearly understand what treatment has taken place in conjunction with the state mandated guidelines. When UR organizations have the proper documentation, they can make the best determinations and avoid the appeals process entirely.

Sometimes, despite an appropriate UR decision, a claimant and/or physician may be dissatisfied. This dissatisfaction may come from frustration. Patients may be upset that they aren’t getting better with the course of treatment, and physicians may feel they’ve tried everything and nothing has worked. Requesting physicians and UR reviewers can discuss treatment guidelines, as well as prior medical treatment, to determine the validity of the current request as it applies to evidence-based medicine.

The checks and balances in the UR system help ensure patients receive the proper and necessary treatment. Dissatisfied physicians and claimants have recourse to appeals processes (based on jurisdictional rules) in the event that they are concerned with the integrity and accuracy of a UR decision. These appeals processes allow UR organizations to review additional medical documentation and further attempt to have successful peer-to-peer conversations between requesting physicians and physician reviewers.

Karen Atkins

Karen Atkins, Chief Operating Officer with UniMed Direct, is leading the conversation, and the industry, on how to make the utilization review process more efficient for all stakeholders: physicians, insurance companies and, most importantly, patients.