Many states are beginning to require specific forms for utilization review (UR). In California, New York and Louisiana, all parties in the UR process, including treating physicians and peer reviewers, must submit requests and decisions on state-stipulated forms. This requirement has the potential to benefit the UR process but also poses a set of challenges.
State Forms Can Improve Consistency of Treatment Requests
State forms can make treatment requests clearer, resulting in more efficient processing. For example, California rules previously stated that physicians could request treatment requests on any form. At the same time, the regulations said that if a UR organization did not respond to a treatment request in the allocated timeframe, the requested treatment was assumed to be automatically approved. This lead to some physicians gaming the system by including treatment requests with billing forms or buried in documentation submitted, and not clearly denoted.
When treatment requests were included within the billing, claims personnel were processing bills without knowing to review for treatment plans within the documentation. The UR requests would sometimes go unnoticed until it was past the response deadline, deeming the treatment automatically approved.
Some states are now requiring UR requests to be submitted on specific forms. This makes it easier for UR providers to receive treatment requests in time to properly review them. This creates a more consistent approach in which requests cannot be placed within bills or clinical documentation. States are also starting to require that proper clinical documentation be attached to the required forms, meaning UR organizations will have easier access to the information they need to make effective medical decisions. This is beneficial for all parties as it ensures that requests and decisions can be clearly defined by utilizing CPT (billing) or ICD (diagnosis) codes. The inclusion of the specific treatment information alleviates the delay that occurs when the UR provider or peer reviewer must obtain additional clinical information. Ultimately, the forms help ensure providers will be paid for the correct procedure (based on the UR approval).
State Forms Can Also Pose Operational Challenges
State forms may increase the consistency of processing treatment requests, but they can also make UR processes more cumbersome in some ways. Much of the current UR technology depends on having all the relevant data in a readily accessible computer system. Many states require that the medical treatment provider sign the submitted form and that the nurse/reviewer signs the form upon completion and denotes the decision or other informational sections. As a result, the process requires more advanced systems in order to accommodate the state requirements.
Previously, UR organizations were required to submit decisions only in a letter. In states with required forms, however, UR organizations must produce both the letter and the form. This may increase UR organizations’ workloads and adversely impact their processes if they are not equipped properly or if their software cannot meet the statutory requirements.
There is value in state-required forms that clearly define the content of a request, as this allows for more efficient processing of treatment requests and eliminates the need to delay processing to request additional information from the treating provider. However, the form system is not perfect, and while the intent is to ensure treatment requests and determinations are clear and concise, state-of-the-art UR software is required in order to avoid operational slowdowns. All parties involved in processing UR requests will have to take the good with the bad in states that require forms.