Injured workers, physicians, insurance carriers, utilization review (UR) agents, nurses and policymakers are dependent links in the UR process. Simple mistakes cost time and money for all types of stakeholders. But with focused, streamlined processes and software, you can get UR right the first time.
Ask yourself these questions to save on UR resources:
1. Is the requesting provider knowledgeable with evidence-based guidelines and has the appropriate clinical documentation been submitted to support the request?
Fast to Yes: A request supported with clinical documentation and using the best available evidence is more likely to be approved than a request with unclear information. All stakeholders play a factor and contribute to the success of the healing process.
2. Has all critical information been received and read by the right person in a timely and thorough way?
Easy to Know: Evidence-based decisions can assist in managing or reducing costs (both time and money) for all participants by ensuring the right care is provided in a timely manner. While not all states have adopted guidelines, those that have continue to see improvements in care and timely results. For states that have not yet mandated guidelines, there is still an opportunity to utilize evidence-based guidelines to ensure timely quality care.
3. Are all parties coming from a cooperative perspective?
Fast to Yes: Peer-to-peer conversations between physician advisors and requesting physicians can be challenging, but they’re crucial in the review process. Answering calls quickly and with a collaborative approach will help your team perform cost-effective UR with optimum outcomes.
4. If a treatment is denied, is the reason clear?
Easy to Know: Providing claimants with clear rationale for denials can alleviate concerns and assist in understanding the reasoning for the denial. It also allows the claimant to be part of the solution in ensuring that their medical provider is cooperative and working collaboratively to prevent problems and reduce re-reviews. Fully understanding the additional information required allows providers to effectively engage in peer-to-peer conversations or, when necessary, in the appeal process.
Think of UR as a cake: without one key ingredient, the cake can’t rise. By asking the right questions at the beginning of a request, UR teams can more consistently achieve positive outcomes (the cake, frosting, and the ice cream!)
Do you have more questions? Ask our experts today!