Who are the UR Stakeholders, and What are Their Pain Points?

| | Utilization Review

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Stakeholders
Many view utilization review (UR) as a process that occurs between two parties: an insurance company and a health care provider. In truth, a variety of stakeholders play important parts in UR. Injured workers, most importantly, initiate the claims. Insurance companies pay for treatment and time off work, UR nurses approve routine treatment requests and physician peer reviewers ensure patients receive the proper treatment. Also, injured workers’ employers need to stay informed of the employee’s work status and provide a return-to-work plan. Each participant in the UR process has priorities and concerns. This article explores each stakeholder’s priorities and offers ways that UR companies can make the process run effectively for each participant.

Insurance Companies, TPAs, and Managed Care Companies

Insurance companies, Third Party Administrators (TPAs), and managed care companies oversee the health care programs of other companies. Insurance companies cover employers in many differing jurisdictions, so they look to UR companies like Unimed Direct to manage workers’ comp in each area they operate in. They must comply with detailed regulations in each state, so they need UR providers who can help them handle these details easily.

Costs are important to these parties. Insurance companies, for example, want to control their costs, but they don’t want adversarial relationships with providers or injured workers. They simply want to ensure that they aren’t approving claims that should be denied or denying claims that should be approved. Similarly, TPAs contract with employers to help them manage their health care expenditures. TPAs are concerned with showing carriers that they can save costs while approving proper treatment for workers. Like insurance companies, TPAs want to avoid over-approval or over-denial of treatment. Managed care companies perform similar functions as they look to reduce the healthcare costs while improving the quality of care.

Because these parties are all concerned with reducing costs, they need UR processors who help them monitor and manage spending. For insurance companies, TPAs, and managed care companies, front-end UR process costs are less important than paying the right amount regarding the services rendered.

Injured Workers

Injured workers’ main concerns involve getting the right treatment from their doctors. Claimants expect the process to be as smooth and fast as possible, and they expect to understand the communications they receive in the process. For example, if a treatment is denied, injured workers should not receive incomprehensible, jargon-laden letters. They are entitled to thorough and direct explanations in layman’s terms.

UR companies can better serve injured workers by streamlining communication and ensuring patients receive treatment decisions as directly and quickly as possible. If treatment is denied, UR companies need to explain why the treatment was denied in terms that people who aren’t medical professionals can understand.

Healthcare Providers

Treating physicians, requesting physicians, and other care providers are looking for authorization for the treatments they believe are right and necessary. These professionals want peer-to-peer contact with reviewing physicians, not unexplained denials. They appreciate conversation. They want the chance to defend their treatment choices when denial is considered. They also want to know why treatments were modified and to see documentation and clear explanations of why one treatment was recommended over another.

To help treating doctors do their jobs better, UR providers need to encourage and enable communication and conversation between treating physicians and peer reviewers/UR nurses. UR providers need to create a system where information flows easily between treating physicians and reviewing physicians, so that the parties can together make better medical decisions on behalf of injured workers.

UR Nurses and Peer Reviewers

These medical professionals are in charge of reviewing prescribed treatments and approving or denying them according to the best available evidence. UR nurses and peer reviewers both look for the right answers for patients. They are not looking to deny treatment in order to save costs; they are striving to make sure that injured workers receive appropriate healthcare.

Both UR nurses and peer reviewers need information related to the injury. They want to streamline the review process, and they can only do this if they have all of the information upfront, rather than collecting it piecemeal through multiple interactions with treating physicians. UR companies and treating doctors need to ensure that UR nurses and peer reviewers have injury details, diagnosis, medical records, and treatment rationale so that decisions are not delayed and proper care can be rendered as soon as possible.

Employers

Employers, whether self-insured or insured by traditional insurance companies, pay significantly to cover their employees who may get injured on the job. They are concerned about their employees’ well-being and keeping their company productive and profitable. To accomplish both of these goals, employers need to stay involved in the UR process as it relates to the employee’s recovery process and return-to-work status. They also need to provide modified duty when necessary.

Stakeholders in the UR process have different concerns and priorities. UR providers can help by using their expertise to streamline processes and provide all of the relevant information as early in the process as possible.

Stacey Jefferson

Stacey Jefferson, Vice President of Client Solutions for UniMed Direct, is a strategic leader responsible for the company’s software accounts and implementations. Guiding the implementation of innovative technologies to support medical management processes, including utilization review, physician peer review and case management, Stacey is focused on continuous improvement, accuracy and compliance, and the usability of software and technology.