Does Your Utilization Review Cost Too Much and Do Too Little?

| | Utilization Review

For workers’ compensation programs to achieve the Utilization Review (UR) outcomes they need, their UR must do three things: ensure injured workers’ receive appropriate care, control medical and claims costs, and avoid wasting time and money on inefficient processes.

Savvy UR professionals understand that managing medical treatment begins with ensuring appropriate and timely treatment for injured workers. Denying or delaying treatment does not save money over time, but ensuring the right treatment at the right time does. Many industry professionals, however, are unsure about what to look for to keep from overspending for UR services. The following fundamental practices not only help insurers manage claim and medical payout, but also to avoid potentially unnecessary UR expenses.


For many insurance companies and self-insureds it makes sense to outsource UR to third-party UR providers. With an array of UR companies offering a variety of services, deciding which services to outsource to which company and/or which services to perform in-house can be daunting. Based on different jurisdictional requirements, these decisions can include which authorizations can and should occur with the claims examiner, which services should be reviewed by a case manager or UR nurse, and which services need peer review.

Besides comparing costs, an insurer must consider several factors when deciding how to handle UR. Which sourcing option aligns with the business model and financial structure? Does the insurer have the needed competencies in-house? These include regulatory research for compliance, medical director oversight and data collection and analysis for reporting and efficiency? Is the company willing and able to identify, invest in and maintain a solution for capturing the UR information and outcomes? Does the company have the right tools to drive efficiency so the process is not cumbersome and costly?

Rightsourcing UR is a key to managing costs, and making strategic sourcing decisions requires due diligence in evaluating options for who handles which part of the medical management treatment decisions.

Integration – Connecting the Parts

Complete and cost effective UR requires multiple parties to work together – healthcare providers, UR staff, peer reviewers, insurance companies, employers and often other ancillary companies. Providers submit treatment requests, intake people receive and process the requests (data entry and tracking) and reviewers, nurses and doctors have roles that depend on the complexity and severity of each case. Through it all, UR must make medical necessity decisions within jurisdictional guidelines, including strict timeframes.

Lack of integration is one of the most costly problems in the UR industry. This deficiency leads to time wasted, duplication of work and treatment, and inaccuracies – all due to a lack of shared information.

Upfront claim and injury data is imperative to achieve an effective UR process. Likewise, access to UR decisions and information (or the absence of it) proves important when processing medical bills on the backend. It’s the only way to ensure there isn’t a lost medical management effort. For example, if a UR company’s physician reviewer, using evidence-based guidelines, determines that a requested surgery is not medically necessary, and the surgery takes place anyway, what happens with the bill arrives? Will the bill reviewer approve it for payment because the deadline for responding is upon him, and he doesn’t have access to the denial information? In this case, and in countless others, the insurer would pay for UR that served no purpose, increasing the patient’s time off work and exposing him to unnecessary risk.

An integrated UR process requires a strong commitment to communication between all parties and specially designed, customizable UR workflow software. It doesn’t matter where each part of UR takes place, as long as all parties are interconnected in a way that makes the process efficient and shares real-time information.

Automation – Humans Need Not Apply (Sometimes)

In an integrated and efficient UR system, reviews pass only through the steps and people necessary to ensure an appropriate review. This means handling cases at the lowest cost possible without sacrificing quality. For example, when a nurse can approve a request based on evidence-based criteria, there is no need for a costly physician review.

If there is proper and effective integration of claim information with the right oversight and controls, some treatment requests need not flow to a person at all. The right UR workflow software can allow for automatic approvals in accordance with evidence-based guidelines and “kick out” cases that need a review.

Oversight – Maintaining Tight Controls

Insurance companies and self-insureds should carefully monitor their UR partners to ensure compliance, quality and cost effectiveness. A deficiency in any of these areas can be costly.

UR regulations vary by state. When the law is silent, insurance companies and their UR partners must establish procedures to determine which cases should go through which type of reviews. Fees accrued along each step of the UR process can add up quickly, and insurance companies need to set internal controls to manage the costs.

UR performed correctly can be cost effective, but UR performed incorrectly can cost even more in delayed treatment, prolonged time off work and even in fines for lack of compliance. The same practices that make UR efficient and accurate also make it cost less – rightsourcing, integration, automation and oversight.

Remaining focused on the fundamentals discussed above will help insurers manage the costs associated with UR while also getting the most value from it.

Lisa Hannusch

Lisa Hannusch is CEO of UniMed Direct and founder of UR Nation. With experience in virtually every aspect of workers' compensation medical management, she is a nationally recognized authority on effectively managing utilization and medical claim issues. Lisa has direct experience as a healthcare provider, has conducted healthcare fraud investigations leading to prosecution, designed claims and medical software applications, and has worked as an insurance regulator and state agency rule and guideline author. She was an influential leader for requiring evidence-based medical determinations. At UniMed Direct, Lisa has built an industry leading managed care company specializing in ReviewStat – a leader in hosted medical management software, supported with services for UR and a national independent Peer Review Panel.