This is great news for claims and medical management but can present some challenges when onboarding a new client who requests a slightly different workflow, or when complying with a jurisdiction’s requirements that fall outside the automated boundaries. That’s when automation with override controls may be the solution.
Let’s take a few examples that illustrate the need for UR automation with override controls.
- Due date – The jurisdiction due date for utilization review cases is as critical as the due date for issuing indemnity payments to injured workers. While not all states have an established turnaround time for utilization review decisions, in order to deliver timely medical decisions it is critical to have a “due date” built into the utilization review workflow. In a state that does not have a specific turnaround time for completing cases, the “automated due date” may be aligned with URAC standards. For appeals, URAC’s standard is 30 days, which may be an unacceptable automated solution for all clients. In this example, the automated due date will ensure compliance with URAC standards. An automated workflow solution that offers override controls allows entry of an earlier due date to meet client needs, so for example, 10 days instead of 30 days.
- Reviewer qualifications – As a general rule, nurses are qualified to approve medical necessity requests but are not permitted to deny requests. This does not mean, however, that a nurse is needed to review every utilization review request in order to identify which requests should be routed automatically to a physician advisor. Medical directors and utilization review teams can use data analytics to predict the types of requests that should be automatically routed to a physician advisor; for example hip, knee, or back surgery. Using these analytics, automated utilization review workflows can have different override controls for specific clients and/or jurisdictions.
- Medical necessity review criteria – Commercial guidelines, such as ODG and ACOEM, also have automated rules that can automate referrals and decision-making. If integrated into an automated workflow, the override control may be based on jurisdiction. For example, in Texas ODG’s UR Advisor may be used for auto-routing utilization review cases, and Reed Group’s MD Guidelines may be used to control automated referrals and decision-making for Colorado utilization review requests.
Once the utilization review workflow is automated, with or without override controls, requests and decisions can provide a powerful data set for managing and improving injured worker outcomes and increased workflow efficiency.