As medical costs continue to rise, workers’ compensation payors are looking for methods to identify expenses that can be controlled and ways to handle claims more efficiently. According to a Lockton white paper, medical expenses are now averaging well over 60 percent on average claims costs and represent a significant impact on an employer’s workers’ compensation total cost of risk. This trend isn’t going away soon, as this average is expected to climb even higher in the coming years. Utilization review is becoming more and more popular in a number of states as a key method for managing these rising medical costs and ensuring appropriateness of care.
As utilization review becomes more common, many managed care organizations and companies performing utilization review are looking for ways to improve efficiency and better coordinate the efforts of highly skilled medical professionals on a tight timetable. In order to accomplish these goals, many top-performing organizations are turning to technology.
Choosing a utilization review medical management software solution with the right features is critical to ensuring the best bottom-line results for your organization. Historically, stakeholders in the workers’ compensation industry have viewed utilization review as a requirement only in the states where it is mandated. But today, more carriers are making utilization review a priority.
With these things in mind, it’s important to look for a medical management technology system that has features designed to help you make effective utilization review decisions, keep your operations efficient and reduce medical and program costs. Here are seven key features and functionalities to look for when evaluating a medical management technology platform.
- Real-Time Reporting
Don’t wait until the end of the month to get answers to important questions. Your utilization review medical management software should provide the reports you need on a daily, weekly and ad-hoc basis. Real-time data can provide a huge advantage in handling claims appropriately. Often, an individual requesting a medical review can feel as though the carrier is denying requests more often than not. The ability to pull data related to any stakeholder (the claimant, the requesting provider, etc.) with just a few clicks of the mouse often yields the real answer for why this may be. Having the option of one or multiple data parameters can alleviate concerns about excessive denials.
- Efficient Workflows and Staffing Models
Are cases being transferred among team members appropriately? Who needs to review the cases when to ensure processes are cost effective? Choose software that moves and shares information effectively and allows you to easily access this information with data-driven workflows. The vendor who provides the software should provide experts to help you optimize and customize your workflow to both fit your internal needs and improve efficiencies based on data and best practices.
- High Configurability and Flexibility
Choose a flexible system that can easily adapt and change based on business needs. Industry changes are common and often require workflow changes — for example, regulatory compliance changes that cause additional pieces of information to become required are a perfect example of how being highly configurable is ideal. It’s important to be able to adapt the software that you select quickly and with minimal disruption to add new fields that become immediately useful for reporting.
- Regulatory Compliance
A medical management software solution with high automation and built-in compliance workflows are designed to help users make decisions that are compliant with state-mandated and jurisdictional rules. Often, utilization review turnaround times and due dates are highly monitored by either compliance regulations or best practice standards. The jurisdiction due date for utilization review cases is as critical as the due date for issuing indemnity payments to injured workers. And while not all states have an established turnaround time for utilization review decisions, it is critical to have a ‘due date’ built into the utilization review workflow in order to deliver timely medical decisions. If you operate in a state that does not mandate a specific turnaround time for completing cases, you could consider setting an ‘automated due date’ within your workflow to align with URAC criteria.
- Responsiveness as a Service
Both your software system and the people who service it should be responsive so that you can be responsive to your customers. Without high quality data, it’s difficult to respond to your clients. Your system should provide information to easily arrive at solutions that are within your parameters. Additionally, flexibility in extracting data from medical management software allows users to run reports according to custom parameters. Whether sorting data by client, provider, nurse, or outcome, every report should reveal answers to specific questions or help you identify where to look more thoroughly.
- Data Mining
A powerful utilization review medical management software solution should not only collect data, but it should also aid you in analyzing that data. Data should be readily exportable to other applications such as Microsoft Excel, and you should be able to “slice and dice” the data according to specific factors that are most important to your operation. Ultimately, you need a medical management software that offers powerful reporting tools that help you efficiently enter cases into the system and return required information to treating or referring physicians once decisions are made. It should also track the time taken for each step of a case and show who is working each case at any given time to help you manage both team efficiency and case outcomes.
- Secure and Encrypted Features
Security and encryption is an extremely important factor to consider when selecting a medical management software partner. Be sure that the software provider is well-versed in security and encryption methods appropriate for communications between users and the software.
A utilization review manager or supervisor needs the right software to work as efficiently as possible. To do your best work, be diligent in choosing the best software available for your specific needs.
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