UR Beyond Expectations - Utilization Review in Workers' Comp


UR Beyond Expectations


Utilization Review in Workers' Compensation


What comes to mind when you hear the words “Workers’ Compensation Utilization Review?” Unfair, delay in medical care, unnecessary fees to the claims administrator, non-integration with Bill Review, the “Dark Side,” or maybe all of the above?


Six years ago Health Strategy Associates (HSA) completed the first survey of Utilization Review (UR) and Utilization Management (UM) in workers’ comp. Joe Paduda stated that some of the big findings included: Most payers’ primary UR was done by in-house staff, the vast majority of respondents used UR to control medical costs and ensure appropriate medical treatment, executives surveyed were more concerned with implementing states’ UM/UR guidelines, while desk-level folks were more worried about states’ poor enforcement of those guidelines, and while most execs thought UR was connected to bill review, most desk-level folks knew otherwise. He goes on to state that the new survey’s preliminary findings from executive level respondents indicated that no company was recognized as the leader in providing UR services. He mentions that today, management is more aware that UR is not connected to bill review – and surprisingly, it still isn’t.


The good news is that I am here to tell you otherwise. Why should you listen to me, you might be asking yourself? I have substantial objective evidence to demonstrate that there is a clear leader in Utilization Review, one that puts all those concerns to rest and lets you sleep without the nightlight on. EK Health Services, Inc. does all of that, and more. With over 20 years of experience in workers’ compensation, EK Health has completed approximately 90,000 Utilization reviews in 2018. EK Health provides workers’ compensation medical bill review (BR), utilization review, medical case management, and other related services to insurers, TPAs and employers nationwide. EK Health has been URAC-accredited for Workers’ Compensation Utilization Management (WCUM) since 2005 (13 years before the DWC required it), earning re-accreditation every two years since. In 2014, EK Health added URAC accreditation for Case Management Services. In their recent 2017 URAC re-accredited audit EK Health passed with a perfect score of 100%.


The HSA survey asserted a notion that there is no clear UR leader in the industry. Perhaps they did not hear that EK Health as a URAC-accredited Utilization Review and Case Management Organization, demands and delivers the highest standards in the industry? As demonstrated by consistent, near-perfect audit scores, EK Health fully understands and embraces the state audit requirements, and provides a truly unique automated solution in delivering consistent, defensible, quality UR determinations.


Some UROs may state they are the leader, or that they offer integrated UR and BR, but only EK Health can say that with tangible evidence to support this statement. EK Health’s most recent twenty-five (25) DWC audits returned a combined average score of 99.5%, with seventeen (17) DWC audits achieving a score of 100%.


EK Health has built a team filled with industry leaders to provide the highest quality UR. Their Medical Director, Dr. Douglas Benner, sits on several California DIR/DWC Technical Advisory Groups, including current boards meeting on workers’ compensation fraud, physician reports, and physician survey on access to care (with RAND Corp), the medical advisory review board for ODG where he actively participates in guideline development, and is involved with the advisory board for Presley Reed medical disability guidelines. In addition to these development roles for evidence-based medical guidelines, Dr. Benner was recently nominated by ACOEM to be the single joint representative of ACOEM and Presley Reed on a new ACOEM Guidelines Priority Committee. EK Health has an in-house General Counsel coupled with a management team specifically for compliance & regulations to ensure that their UR is compliant in every facet. This team sets out to produce UR the way it was intended to be.


With all the perceived dismay circling UR, some claims administrators have resorted to simply having their claims examiners review the medical treatment on the treatment Requests for Authorizations (RFAs) and decide if they can approve without much training, or basis on how to render a decision on what to allow as medically necessary. This is where EK Health can step in and make an immediate impact on how UR is addressed at the front line. EK Health UR offers systematic logic backed by data integrity that is in line with the required medical treatment guidelines, and takes into account the industry trends from both overall UR dispositions on specific treatment, voluntary appeals and even IMR Final Determinations. By factoring in all phases of medical review, EK Health can make solid recommendations on what exact treatment is actually medically necessary and brings with it a high propensity to be approved based on guidelines and current trends.


EK Health works closely with its technology partner, who has developed such software and even offers a software-based decision engine as an option for the claims examiner to manage incoming treatment requests for authorization. This proprietary software provides an extraordinarily stable, expandable, customizable platform for seamlessly integrating a claim’s bills, medical records, clinical review/management documentation, and other supporting documentation in one secure environment. If an RFA is determined to warrant submission to formal UR, there is a seamless electronic referral process to UR within the system. This integration requires a simple “click” and all documents and the RFA are routed to formal UR for immediate handling. This process expedites handling and allows for optimal savings to lower costs for the claims administrator.


Because EK Health UR houses all treatment history, it is easy to look back at the authorization history to look for duplicate treatment requests, and halt the UR process if needed. Quickly and accurately identifying duplicate requests enables EK Health to contain costs and prevent unnecessary UR fees that may even culminate in unnecessary appeal and IMR fees too.


So, you may be wondering how EK Health makes UR truly integrated with BR? Simply put, all treatment is procedurally coded (i.e. NDC, CPT) at the line level for integration with their Bill Review platform to ensure only approved treatment is paid for. What’s worse than paying for UR up front, but only to pay for denied treatment in the back-end because BR is not “talking” with UR? That defeats the whole purpose, and increases medical spend unnecessarily. Authorization date ranges are also defined, taking into account projected surgeries and duration of medications to name a couple, that enforces only medically necessary care within the allowed time frame approved. This integration prevents payment for non-approved treatment that commonly results from miscoding and treatment rendered outside of the certified date range.


Understanding the opportunity to establish controls, EK Health has partnered front-end utilization and treatment plans with back-end payment processes, engineering technological and operational workflows for best in class solutions. After UR is completed by EK Health, bills are presented on the back-end, and all treatments are programmatically matched to elucidate prior UR recommendations for payment. If treatment rendered does not have a corresponding UR decision, the bill will pend for the claims administrator’s review. If the bill presented for payment has a corresponding UR decision to pay, the bill will be handled programmatically without human intervention. This is true automated integration systematically between UR and BR. The front-end process is equipped to house customizable rules based on the utilization review program and has customizable BR based on client-specific rules. EK Health’s BR integrates with UR decisions in many more ways which prevents unnecessary payments including but not limited to Prospective UR never requested, UR non-certified the treatment that was rendered, treatment rendered was outside the timeline allowed in UR, treatment exceeds the certified units allowed in UR, treatment rendered by non-authorized providers, treatment rendered on denied claims or non-accepted body parts, and/or treatment rendered on a closed claim.


What makes the UR determination defensible? It starts with making the right decision the first time by utilizing the best suited physician reviewer, specialty matched that understands how to cite the appropriate guideline hierarchy, and tie in the clinical correlate into the rationale. Another differentiator is that EK Health requires Physician Reviewers to make and document concerted efforts to speak with the treating provider with all adverse decisions and to work collaboratively and determine that all relevant medical information is understood prior to issuing a denial or modification. Peer dialogue significantly reduces the number of requests going to voluntary appeal or IMR because of ongoing education with the treating doctors to better understand how the guidelines were used and the need for proper documentation.


When processing an RFA with multiple items, EK Health has the system functionality to split the request apart so that all items can be reviewed at the lowest cost level possible; however, the system connects all treatment lines so that the entire RFA remains connected in a comprehensible reporting format to all stakeholders. For example, EK Health uses proprietary software that allows the claims examiner to readily authorize treatment that has been recommended based on systematic logic pre-defined based on the medical treatment guidelines and any combination of allowable threshold based on the claims administrator’s approval. This technology then allows other RFA items to be split to address other administrative dismissal scenarios for treatment that may include denied body parts, a denied claim or a non-MPN provider as examples. Alternatively, if the treatment cannot be addressed by any of these methods, a referral may be made to escalate to formal UR. This work flow allows only the small amount of RFAs to ever eventually be sent to a UR physician reviewer. This expedites medically necessary care to the injured worker, and also eliminates unnecessary claims cost to the claims administrator. Clients look to EK Health instead of the larger managed care organizations because of the managed care solutions they can offer, reduced medical costs, increased savings, improved return-to-work results, reduced litigation and expedited care.


The evidence is obvious and glaringly transparent that EK Health has been functioning at a high level to deliver consistent, quality, defensible and cost-containing UR for over 20 years. While the HSA survey makes a generalized statement that there is no clear leader in UR, it is quite hard to argue that EK health wouldn’t be considered among the leaders, if not the leader in California workers’ compensation UR. From the advanced technology offered through the proprietary software to the clinical and leadership excellence, they have developed a reliable product that will certainly benefit any claims administrator that is interested in handling UR in the most efficient, accurate and systematic approach available today. Finally, and most importantly, EK Health every day keeps with their vision to transform managed care with everyone in mind. What this means is that EK Health goes above and beyond to do what is right for the injured worker, physicians and payers.  


Glenn Crafts, D.C., Q.M.E.
Assistant Vice President, Utilization Review & Quality Assurance