The Doctor Will Review You Now

Risk & Insurance Online - January 2012 - By David Huth

When doctors -- not nurses -- conduct utilization reviews, cases are handled more smoothly.

Personally, I have always been somewhat skeptical of the long-term value of utilization review in controlling workers' compensation medical costs. While utilization review regulations can definitely limit potential over-utilization of medical care, they generally are most effective in the immediate year or two after implementation. Over time, treating providers either quickly learn to ask for more treatment than they really need (in order to get what they actually want) or they become experts in the clinical guidelines used in many utilization review programs and know exactly which procedures or how many visits will be permitted for common workers' compensation diagnoses.

In the first scenario, the utilization-review system devolves into a ridiculous version of the children's game of Mother May I, with treating providers asking for 12 physical therapy visits, knowing that the managed care utilization review nurses will gladly allow eight as long as they are then permitted to claim a "hard savings" of four visits for their clients.

In jurisdictions where the utilization-review criteria is publically available or based on popular evidence-based guidelines, treating providers are forced to submit their requests to utilization-review programs even though they usually know up front that their proposed treatment plan is well within the guidelines. In either scenario, employers and insurers typically end up paying significant review fees to get what amount to rubber-stamp approvals from the managed-care firms' utilization review nurses on 60 percent to 70 percent of all cases.

So I was especially dubious on a recent visit to Paladin Managed Care Services in California which had seen great success with a new approach to utilization review that actually used physicians rather than nurses to review all treatment requests. Initially, I assumed that the company was simply taking advantage of the growing offshoring trend to use telephonic physicians in someplace like the Philippines to staff their utilization-review program at costs that would be comparable to programs that used U.S.-based utilization-review nurses. In reality, their program relies on U.S.-based physicians who remain in active practice, which led me to suspect that their program must cost a fortune and the results must be absolutely terrible. After all, why would anyone use higher-cost physicians to review treatment requests where the vast majority of care ends up getting approved as requested?

However, as I learned more about the program I realized that not only does the model actually succeed, but it also has created a unique opportunity for the company to build important connections with treating physicians. The organization's chief operating officer said that staffing their program with physicians has given them much better access to treating physicians, which in turn has led to faster utilization-review decisions and a better ability to actually impact treatment requests. In most managed-care operations, the utilization-review nurses have very little meaningful interaction with the treating physicians, dealing instead with office administrative staff on process-related issues such as whether all the required documentation has been submitted along with the treatment request. By design, most utilization-review programs do not allow nurses to deny treatment requests if they do not meet the clinical guidelines. Instead the nurses are limited to either simply approving requests that clearly meet the criteria or are forced to play the negotiation game with the provider's office, asking "would you accept eight physical therapy visits instead of 12?" Treatment requests that cannot be approved by the nurse are instead handed off to physician advisors who repeat the process of comparing the original request to the guidelines while also factoring in their clinical judgment. If appropriate, they will then reach out to the treating physician for a peer-to-peer conversation. The process of using utilization-review nurses to essentially pre-screen the treatment requests ends up adding delays to the typical utilization review decision-making process, but the general consensus is that you should only send the cases that fail the clinical criteria to a physician advisor since they are a more expensive resource.

The company's model turns that notion on its head, instead suggesting that by removing the nurse from the initial review process, they can actually improve the outcomes of the process -- both from a timing perspective and ability to impact treatment plans, while keeping review costs competitive. Clearly, the organization has been successful in streamlining the process, averaging less than one business day between receipt of a concurrent review request and a determination by their physicians. The chief operating officer believes that this is largely due to the fact that since a physician is calling the treating provider's office, they get quicker access to the information required to complete the review if not immediate access to the treating physician themselves. Somewhat counter-intuitively, their average cost-per-review has also remained in line with its competition. Although its cost for reviews that meet criteria might be higher than competitors who use only nurses rather than physicians, its cost for reviews that would normally require both a nurse and a physician advisor should be below industry norms, meaning that on an overall basis their cost remain competitive.

While URAC accreditations and detailed state utilization review audit results clearly show that many organizations that do a good job of managing the basic utilization-review process and several of the premier managed-care firms excel at leveraging their physician advisors to intervene on treatment requests which fall outside of the clinical guidelines, the incremental value of using utilization-review physicians for the first level of reviews may be reflected in the company's results. The percent of utilization-review cases which result in some sort of financial savings (either denied or altered treatment plans) is 10 percent to 15 percent higher for the physician-centric model than I have seen anywhere else.

While I do not have any hard data to prove it, I suspect that the improved savings results may be due to the fact that the utilization review physicians are seeing requests that never would have made it to them in the traditional model. Requests are being reviewed by a utilization-review physician who reaches out to the treating physician with additional questions or suggestions for alternatives.

Ultimately, it was that aspect of the physician-centric model that intrigued me the most. It appears as if rather than treating the utilization-review process as a simple pass/fail test for specific treatment requests, using utilization-review physicians to conduct the first level of reviews has opened an additional critical channel of communication with the treating physicians on a wider array of claims. This type of peer-to-peer dialog with the treating physicians ends up being remarkably similar to industry best practice models we have seen in top tier workers' compensation claims payers who have embedded physicians in their claims teams or leveraged their medical directors specifically to reach out to treating physicians regarding their proposed treatment plans and/or injured workers' ability to return-to-work on problem claims.

Whether you adopt the physician-only review model or simply work to identify a way to better leverage the more traditional nurse/ physician advisor utilization-review model across a wider swath of claims, perhaps the greatest value of the process in workers' compensation is to provide a mandatory trigger point for precisely that sort of constructive dialog between clinicians. By forcing treating physicians to reach out for approval at a critical point in the life of a claim -- just as they are preparing for a new course of treatment, a major diagnostic test or even a surgical procedure -- and by using that opportunity to initiate more peer-to-peer conversations, perhaps the process can provide a unique opportunity to improve outcomes for injured workers and savings for employers/payers



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