UR Management Software: Friend or Foe of the UR Process?

| | Technology & Integration, Utilization Review

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Lisa Robinson Aug 2018 Article on ReviewStat
When debating the value of utilization review (UR) for injured workers, opinions vary widely based on what role a stakeholder or system participant plays within the UR process. One would be hard pressed, however, to find anyone in the workers’ compensation arena who would argue the value of timeliness and quality in issuing medical necessity decisions that facilitate optimal outcomes for the injured worker. Unfortunately, the UR process can be complicated and riddled with inefficiencies that can contribute to sub-optimal performance. This is especially true given all of the state-specific UR rules and accompanying approaches to medical management.

Why is the UR Process so Complicated?

Utilization Review Organizations (UROs) face many challenges in delivering what sounds like a simple process: treatment request received, documentation reviewed, and decision sent out. The complication lies in the many internal processes and external regulations that drive UR before a decision about treatment can be issued. This raises an important question for consideration. How do UROs ensure they are operating efficiently and delivering high quality medical necessity decisions? A key answer lies both in the software and users’ ability to interact with the software.

How can UR Software Contribute to Better Outcomes for Injured Workers?

The tipping point to achieving quality and timely decisions happens when software can make decisions that do not need human involvement. Another key factor is how efficiently users are able to interact with the software. ReviewStat is a UR management software program specifically designed to handle every aspect of the UR process with ease and efficiency. Through automation tools, artificial intelligence, and customizable workflows that streamline jurisdictionally compliant UR processes, ReviewStat maximizes human resources for more extensive review roles, such as medical necessity review.

ReviewStat has functionality to issue evidence-based treatment approval decisions, fax letters, and communicate, all without human intervention. However, when a treatment request needs human medical review, the software is able to provide clinical professionals with the tools and resources needed to get quality medical necessity decisions back to the injured worker timely. In order to make quality medical necessity decision timely, the clinical reviewer needs three key things at her fingertips: (1) the injured worker’s medical history, (2) evidenced-based treatment guidelines, and (3) a way to efficiently communicate with all stakeholders.

ReviewStat exceeds expectations by presenting clinical reviewers with an injured worker’s entire claim history at the time of the treatment request review, providing a more holistic approach to medical necessity decision-making. One national standard for evidence-based treatment guidelines to guide treatment decisions would be ideal, but currently many states differ in what treatment guidelines must be used in the UR process. ReviewStat not only removes this complication by providing access to all state guidelines, but also informs clinical reviewers which ones specifically apply to the treatment under review. Finally, the icing on the cake lies in the communication tools available within the software for clinical reviewers. The communication tools ensure streamlined processes are in place to communicate with all stakeholders involved in the review process, promoting optimal outcomes for the injured worker.

Managing the UR process can be both complicated and time-consuming for UROs. But the good news is ReviewStat provides a software platform that is customizable, jurisdictionally compliant, and integrates intelligent solutions to ensure clinical reviewers have the information they need to issue quality medical decisions. And the correct decision, rendered timely, is definite win-win for all stakeholders.

Lisa Robinson

Director of Quality and Medical Technology for UniMed Direct, Lisa works hand-in-hand with the technology department to design and build advanced clinical decision support within the ReviewStat system. Her intent is to help clients, physicians and all other related healthcare professionals better manage the utilization review process.