3 Steps to Mastering Utilization Review

Efficient UR management is essential not only for compliance but also for enhancing the well-being of employees, reducing costs, and minimizing legal risks. Below, we explore some key strategies to optimize your UR process.

Key Strategies

According to a study published in the Journal of Occupational and Environmental Medicine, delayed medical care can lead to prolonged recovery times and increased disability duration, which in turn can negatively impact the overall outcome of workers’ compensation cases .

Prioritize Timely Medical Care

Speed isn’t just about compliance; it’s about the well-being of the injured employee. When UR decisions are made promptly, you can avoid unnecessary delays leading to quicker treatment, which can prevent complications, and the likelihood of an employee requiring additional or more extensive treatment. It’s a win-win for everyone.

Stay on Top of Regulatory Compliance

Understanding and adhering to legal requirements for UR is non-negotiable. Many states have strict guidelines on how quickly UR decisions must be made—typically within 3 to 5 days. And here’s a key detail: the clock starts ticking the moment the adjuster gets the treatment request, not when it’s sent to UR. For anything marked as STAT, RUSH, or EXPEDITED, the turnaround time (TAT) could be much shorter. Staying compliant not only keeps you on the right side of the law but also shields your company from potential fines and legal headaches.

Minimize the Risk of Litigation

One of the biggest headaches in workers’ comp is litigation – its something we are all trying to avoid. An inefficient UR process can make this difficult to do. If injured workers are not provided with timely care and treatment they are more likely to seek legal representation. In fact, according to PropertyCasualty360, the percentage of insurance claims that went into litigation rose 47% over a four year period.  When UR decisions are timely and treatment is not delayed, injured workers are less likely to feel the need to seek legal representation. They’re getting the care they need when they need it, which can lead to higher satisfaction with how their claim is handled and lower chances of disputes.

Utilization Review (UR) management is more than just ticking boxes. There is a noticeable different when you improve your compliance efforts, and speed up medical care but to do this you need a knowledgeable team of UR specialist or nurses that have experience with medical necessity requirements. Take time to train, certify and teach your staff and improve the process for everyone involved.

Attend one of our purely educational medical management webinars here. Our topics are updated every month so if you don’t see one you like just reach out to us at ce@ethosrisk.com for more information.

Resources:

U.S DOL: https://www.dol.gov/sites/dolgov/files/odep/topics/pdf/rtw_role%20of%20physician_2015-03.pdf

Journal of Occupational and Environmental Medicine: https://ohguides.acoem.org/07-psychological-factors-and-workforce-health-delayed-recovery-from-injury-or-illness/

Property Casualty 360: https://www.propertycasualty360.com/2022/09/13/emerging-factors-forecast-a-continued-rise-in-insurance-litigation/?slreturn=20240830113658