Organizing UR Data to Achieve Workflow Efficiency

| | Technology & Integration, UR Software, Utilization Review

Jaelenes July 2016 Article on Workflow Efficiency

Big data is a frequent discussion topic in the workers’ compensation industry, as well as in the health insurance industry. Much of the discussion focuses on data intelligence, but data collection and storage also present opportunities to achieve workflow efficiency.

During every patient encounter, health care providers capture data. They then share it with others in the form of Electronic Health Records (EHR), medical billing data and utilization review requests. Several states mandate electronic exchange of medical billing and payment data. While only a few states mandate the format for exchanging data for utilization review requests, other states do specify the information that must be included in utilization review requests and outcome decisions. This provides the opportunity to standardize data collection and exchange of information in all states that require or authorize utilization review.

The opportunity begins with identifying which information is required to be exchanged, regardless of format. The data that is “received” on the request is generally the same data that is required to be included on the “outcome report” (i.e. utilization review decision or report). The data stored in a health care providers’ EHR system could be aggregated to generate a “standard” utilization review request that is auto-populated for each patient. Once this patient-specific request is submitted to the insurance carrier or  its utilization review agent, the data can be stored  and used to achieve workflow efficiency. For states that allow the opportunity to request additional medical information from the requestor, a standard letter or form can clearly outline the information needed and succinctly capture the collected demographic data on file. This can streamline the process for what and how providers  send information back and help ensure an accurate and timely review of the requested medical treatment.

If the California Legislature adopts AB 2883, the Commission on Health and Safety and Workers’ Compensation would be required to conduct, or contract for, a feasibility study regarding the extent to which physicians’ requests for treatment authorization may be processed using an entirely paperless system. The bill provides that the focus of the feasibility study shall be to determine whether the change to a paperless system would reduce the time required to provide medical services to injured employees and improve the clarity and quality of communication between physicians and the utilization review provider.

One opportunity to achieve efficiency after a utilization review request is received is to use a standard “peer to peer” form. For insurance carriers with multiple utilization review agents or physician advisor panels, a “peer-to-peer” form can bring uniformity to the presentation of information the requesting physician submits and organize the physician advisor’s case review and medical necessity decision. This uniformity can bring consistency to decisions, expedite the review time-frame and facilitate quality assurance reviews.

Standardized outcome report templates that use a combination of the collected utilization review case data along with results generated from evidence-based guidelines can produce clear and simplified notification letters that all parties can understand.

Automating state-mandated forms provide another workflow efficiency opportunity. An example is the CA IMR form. Data received from the requesting physician, the utilization review decision and the carrier’s claim demographic data can be integrated to auto-populate the form.

The opportunity to integrate insurance carriers’ claim data with utilization review requests and decisions exists without state legislation or regulations. This integration can increase work-flow efficiencies for requesting physicians, insurance carriers and utilization review companies. Once the utilization review data has been aggregated, the data can also be integrated into bill review platforms to improve medical bill review efficiency for services that have been prospectively or retrospectively reviewed for medical necessity.

Jaelene Fayhee

Jaelene Fayhee

Jaelene Fayhee, AVP, Client Solutions for UniMed Direct, is a regulatory expert who works hand-in-hand with clients and the technology department to deliver technology and medical solutions to clients. Jaelene is focused on using technology to ensure compliance with current and upcoming regulatory requirements and delivering prompt and appropriate decisions to expedite medical decisions for injured workers.