Unnecessary Treatment: Why It Happens and How UR Can Stop It

| | Evidence Based Medicine

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Unnecessary Treatment
Unnecessary medical treatment occurs for a number of reasons. Utilization review (UR) presents an effective defense against such treatment by ensuring that doctors progress through treatment options according to the proper guidelines.

How Money – And Unscrupulous Attorneys – Can Cause Unnecessary Treatments

Evidence-based treatment guidelines are expressly designed to help doctors navigate through the treatment continuum – starting with the least invasive treatments – so that patients are not hurried into surgery when another option, such as physical therapy, would effectively cure their ailments.

Still, unnecessary treatments sometimes occur. Doctors may recommend invasive treatments in part because the procedures have higher profit margins. For example, spinal surgeries often cost between $30,000 and $40,000, due to the highly technical nature of the surgery and the expenses associated with spinal implants. Therefore, some doctors may pursue these options, rather than trying less invasive treatments first.

Attorneys may also spur unnecessary treatments by submitting claims outside of the normal network and then suing to get unnecessary treatments their patients think they need. In this case, unnecessary treatments can occur when people do not follow the proper UR procedures.

Surgery May Not be the Only Option: How UR Prevents Unnecessary Treatment

While UR may not stop the actions of certain unethical lawyers, it can prevent doctors from getting paid for performing unnecessary treatment.

When a UR provider receives a request for an invasive treatment, such as a surgery, the reviewing doctor makes sure that the clinical documentation indicates the treating doctor first attempted less invasive treatment. If the clinical findings do not support that conservative treatment has been exhausted or extends outside of guideline recommendations, reviewers reach out to the requesting physicians.

Often, a peer-to-peer conversation reveals that the requesting doctor did attempt less invasive treatment and that the documentation was simply missing from the file. In cases such as these, UR doctors can request supporting documentation based on the conversation and consider the additional information when determining if medical necessity has been established for more invasive treatment.

If the requesting doctor has not exhausted less invasive treatments and cannot offer clinically sound reasons for initiating invasive treatment, UR doctors can deny the request.

Unnecessary treatment can happen; however, UR doctors can be an important defense in preventing it. By requiring requesting doctors to clinically support treatment recommendations in conjunction with evidence-based guidelines – rather than heading immediately toward expensive, invasive and sometimes harmful treatments – UR doctors can help ensure that patients receive the least invasive treatment option to effectively treat their ailments.  

Zenia Cortes, MD, Orthopedic Surgeon

Dr. Zenia Cortes brings her combined expertise in sports and orthopaedic medicine to UniMed Direct, along with insights from her experience in peer and utilization review.