©2010 Coventry Health Care. All rights reserved. Proprietary – Do not copy, distribute or disclose without permission of Coventry Health Care. Provided by Coventry Health Care ® California Medical Bill Reviewer Re-Certification Unit 1: Workers Compensation Benefit Program Module 5: Utilization Review

CA Regulations Training – Utilization ReviewMarch 2010 What is Utilization Review? Utilization Review (UR): a process that provides approval for medical services provided to the injured worker. Purpose of Utilization Review Utilization review is used in an effort to discourage the use of unnecessary or inappropriate medical services, without jeopardizing necessary high- quality care.

CA Regulations Training – Utilization ReviewMarch 2010 What is Utilization Review? Utilization review provides case by case assessments of the frequency, duration, level, and appropriateness of medical care. By determining if medical treatment was or is necessary, utilization review: Manages costs of health care. Improves patient care. Improves decision making regarding necessary treatments.

CA Regulations Training – Utilization ReviewMarch 2010 Utilization Review in California California law requires that employers pay for all medical care reasonably necessary to treat an injured worker. It is important to remember that UR does not guarantee payment or approve charges for specific services. Utilization review processes facilitate this requirement by approving the services that are provided to an injured worker.

CA Regulations Training – Utilization ReviewMarch 2010 Stages of Utilization Review Utilization review can be divided into three stages of treatment: Retrospective Concurrent Prospective

CA Regulations Training – Utilization ReviewMarch 2010 Prospective Review Prospective Review: review and authorization before the treatment begins. Prospective Review If the physician recommends a surgical procedure be performed, authorization from the insurance carrier is requested before the surgery occurs. Authorization can also be required for diagnostic services such as MRIs and CT scans, referrals to specialists, physical therapy, and certain durable medical equipmen t.

CA Regulations Training – Utilization ReviewMarch 2010 Concurrent Review Concurrent Review: review and authorization during treatment. Concurrent Review Most commonly occurs when additional days of service, such as hospital inpatient days, are requested for the patients care. Authorization can also be required when additional physical therapy or chiropractic sessions are needed.

CA Regulations Training – Utilization ReviewMarch 2010 Retrospective Review Retrospective Review: review after the procedure has occurred, but was not pre-authorized. Retrospective Review This is a riskier practice for the provider, as the insurer may not feel the service was required and deny payment.

CA Regulations Training – Utilization ReviewMarch 2010 Utilization Review: A Tiered Approach There are three levels of utilization review. Initial Reviews Second Level Reviews Third Level Reviews

CA Regulations Training – Utilization ReviewMarch 2010 Initial Reviews Initial reviews: reviews usually performed by registered nurses. Initial Reviews Hmm, why are so many tests requested? Registered nurses may: Authorize treatment. Request additional documentation. Pass the request on to second level review. The initial review commonly utilizes software based on national criteria that: Links diagnoses to services performed. Reviews all submitted documentation.

CA Regulations Training – Utilization ReviewMarch 2010 Second Level Reviews Second level reviews: reviews performed for more complex services or those services that have been denied per an initial review. Second Level Reviews Surgery for a broken toe??? Per California regulation, second level reviews are performed by licensed physicians. Only a licensed physician may delay, modify, or deny requests for authorization of medical treatment for reasons of medical necessity.

CA Regulations Training – Utilization ReviewMarch 2010 Third Level Reviews Third Level Reviews: reviews performed to resolve disputes or the lack of a timely response to a UR request. Third Level Reviews Approved! Denied! Approved! If a reply to a UR Request is not given within seven days, or there is a dispute concerning authorization, the injured worker or his representative may file a Request for Expedited Hearing.

CA Regulations Training – Utilization ReviewMarch 2010 Requests for Expedited Hearing Requests for Expedited Hearing are submitted to the Workers Compensation Appeals Board. Only an M.D. not previously associated with the claim can oversee an appealed denial of authorization.

CA Regulations Training – Utilization ReviewMarch 2010 Goals of Utilization Review Utilization review accomplishes the following: Gives the provider the reassurance the services are approved & will be compensated. Allows the insurer an opportunity to evaluate the medical necessity of the services requested. Provides the injured worker the necessary treatments to recover from injury and return to work.

CA Regulations Training – Utilization ReviewMarch 2010 Summary What Utilization Review is, and how it works. The difference between prospective, concurrent, and retrospective treatment reviews. The Tiered Approach: Initial, Second Level, and Third Level Reviews. How Utilization Review helps the insurance carrier, provider, and injured worker.