Oft Criticized Utilization Review in Workers’ Comp Not Just About Savings

April 27, 2016

While critics say utilization review (UR) in workers’ compensation claims is nothing more than a cost savings mechanism, an industry expert outlined its benefits recently.

During a multimedia series, Inside Workers’ Comp, Todd Andrew of Genex, a medical managed care provider, explained that the process benefits injured workers by ensuring the treatment they receive is necessary and appropriate for their condition.

“There are definitely those that characterize UR as being nothing more than cost control. But our experience on this side has been that the majority of carriers and employers that we’re working with focus under the underlying purpose of utilization review, our core approach to it, which is making sure that the treatment the claimant receives is medically necessary and appropriate,” said Andrew.

Another criticism is that utilization review removes a treating physician’s autonomy in determining the best course of treatment for the worker.

Not so, said Andrew.

“Similar to how the claims adjuster would retain the oversight and the management of the claim, the treating providers are always going to retain that decision-making process,” he said.

Andrew explained that the UR process supports evidence-based care.

“We only get involved when something seems to be a little bit off. Ultimately, that treating provider is going to create the care plan,” Andrew said. “They’re going to create the direction that they want to go. From our perspective, we’re just making sure that it still does follow the lines that evidence-based guideline dictates.”

Initially, he said, there was a lot of UR volume but that has tapered off as treating physicians have come to understand what appropriate care is. He doesn’t see much change in the process going forward, unless regulations change.

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