Utilization Review (UR) is a term used to describe the process through which an insurance company evaluates a request for medical treatment. A UR not only determines whether or not the treatment is appropriate and necessary, but also examines whether the specific insurance plan covers the services. Within the workers’ compensation insurance industry there is considerable discussion regarding which treatment guidelines should be used to support utilization reviews.
A common misconception regarding treatment requests is that UR companies routinely deny requested treatment. This is not the case. UR is intended to provide timely and correct decisions – decisions based on accurate medical evidence.
Workers’ compensation insurance plans are regulated at the state level. Each state has its own unique rules and regulations. The regulations are sometimes so state-specific that it is difficult to compare one jurisdiction to another.
There are are two national sets of guidelines in place:
- Official Disability Guidelines (ODG), a product of Work Loss Data Institute
- American College of Occupational and Environmental Medicine (ACOEM) guidelines
In addition, a number of states have adopted their own treatment guidelines. State-created guidelines tend to be consensus-based. Often, they are not rooted in significant medical evidence gathered from clinical trials. This type of evidence is important when determining which treatments are effective.
In Oklahoma, for example, the ODG (Official Disability Guideline) was adopted, but the state also made provisions for the state legislature to create its own guidelines in some areas. The guidelines differed, particularly in the area of spinal treatments. Oklahoma’s decision has generated a great deal of discussion in the insurance community about whether these local guidelines for spinal treatment are beneficial or harmful to patients.
States have the option of using ODG, ACOEM, state-specific laws or a combination of the three. A state may have a statute that directs its regulator to mandate specific treatment guidelines, or it may allow a variety of guidelines. In Tennessee, the legislature is considering a law that would require the regulator to adopt a guideline by 2016. Many states have committees or task forces currently evaluating existing guidelines in order to establish their requirements.
Whichever guideline is used, the intent is to facilitate timely decisions based on current medical evidence – decisions that will be upheld. The goal is to ensure that treatment that should be delivered is delivered, and that care that is not medically appropriate — or is potentially harmful — is not delivered. An effective UR process, providing evidence-based decisions, gives patients, doctors and employers the confidence that the treatment being rendered is in everyone’s best interest.