S&h utilization review 7 31 2014

S&H Utilization ReviewS&H Utilization Review

S&H Medical Management S&H Medical Management Services, Inc.Services, Inc.

Updated July 31, 2014

S&H Medical Management Services, Inc.S&H Medical Management Services, Inc. 22

Utilization Review – in the Utilization Review – in the Private Health SectorPrivate Health Sector You cannot be treated for a non-work-You cannot be treated for a non-work-

related accident or condition without your related accident or condition without your group health carrier implementing group health carrier implementing utilization review. utilization review.

If you go to a hospital or medical caregiver If you go to a hospital or medical caregiver for non-work-related problems, someone for non-work-related problems, someone somewhere is looking at the costs and somewhere is looking at the costs and approving what is necessary and approving what is necessary and reasonable. reasonable.

Implementation of UR in non-work-related Implementation of UR in non-work-related settings isn't by accident; it is done settings isn't by accident; it is done because the cost savings are enormous.because the cost savings are enormous.11

11 Keefe, Campbell & Associates Monday Law Update 4-16-07Keefe, Campbell & Associates Monday Law Update 4-16-07


Utilization Review – Recent Utilization Review – Recent Court Decisions in ILCourt Decisions in IL During the year 2011 in 23 out of 32 reported UR During the year 2011 in 23 out of 32 reported UR

disputes, the IL WC Commission ruled contrary to the UR disputes, the IL WC Commission ruled contrary to the UR non-certificationsnon-certifications

In some cases there were inconsistencies noted or failure In some cases there were inconsistencies noted or failure to provide supporting medical records to provide supporting medical records

Attention to detail could avoid easily challenged UR Attention to detail could avoid easily challenged UR reportsreports

Under the new changes to the lL WC Act in 2011, for all Under the new changes to the lL WC Act in 2011, for all treatment reviewed after September 1, 2011, UR treatment reviewed after September 1, 2011, UR determinations MUST be referenced in a written decision. determinations MUST be referenced in a written decision.

Of the cases upheld, the majority of the non-certifications Of the cases upheld, the majority of the non-certifications upheld were related to excessive chiropractic sessions or upheld were related to excessive chiropractic sessions or physical therapy. physical therapy.

Of the surgical cases upheld, the opinions of the IME Of the surgical cases upheld, the opinions of the IME doctor played a significant role in terms of a denial. doctor played a significant role in terms of a denial.

In cases where there are strong disputes, having the UR In cases where there are strong disputes, having the UR can be a benefit when it matches up with and supports the can be a benefit when it matches up with and supports the position of the IME doctor. position of the IME doctor.

Utilization Review -Utilization Review -So What are the Implications?So What are the Implications? Make sure you provide written notice you are invoking URMake sure you provide written notice you are invoking UR Give the provider a reasonable amount of time to provide Give the provider a reasonable amount of time to provide

timely and complete reports of clinical information needed timely and complete reports of clinical information needed to support the requestto support the request

Provide findings of the UR to the provider and employee Provide findings of the UR to the provider and employee An employer may only deny payment or refuse An employer may only deny payment or refuse

authorization on the grounds the extent and scope of authorization on the grounds the extent and scope of medical treatment is excessive or unnecessary based on medical treatment is excessive or unnecessary based on utilization review guidelinesutilization review guidelines

Causal connection is NOT addressedCausal connection is NOT addressed A petitioner must establish by preponderance of the A petitioner must establish by preponderance of the

evidence that a variance from UR standards is reasonably evidence that a variance from UR standards is reasonably required before treatment denied under UR will be required before treatment denied under UR will be awardedawarded



Utilization Review – Feedback from Utilization Review – Feedback from the IL W/C Commissionthe IL W/C Commission When a treating physician recommends medical care and treatment, When a treating physician recommends medical care and treatment,

the employer is obligated to authorize the treatment or must produce the employer is obligated to authorize the treatment or must produce in writing credible evidence to rebut the presumptionin writing credible evidence to rebut the presumption

Per the arbitrators, UR performed by a physician from out of state is Per the arbitrators, UR performed by a physician from out of state is not credible – however in the new WC Act Section 8.7 the reviewing not credible – however in the new WC Act Section 8.7 the reviewing professional must be either available in the State of Illinois for professional must be either available in the State of Illinois for interview or deposition, or be available by telephone, video interview or deposition, or be available by telephone, video conference or any electronic means for remote depositionconference or any electronic means for remote deposition

It is the employer’s burden to demonstrate to the Arbitrator and IL It is the employer’s burden to demonstrate to the Arbitrator and IL W/C Commission that there are concrete standards and guidelines W/C Commission that there are concrete standards and guidelines that exist and to identify and explain how they impact recommended that exist and to identify and explain how they impact recommended care and treatmentcare and treatment

The Commission states UR is being under-utilized. They encourage The Commission states UR is being under-utilized. They encourage taking advantage of the toolstaking advantage of the tools

Goal for UR is to make sure treatment is appropriate, not necessarily Goal for UR is to make sure treatment is appropriate, not necessarily to deny treatment or to determine causationto deny treatment or to determine causation

The Arbitrators will be receiving training on UR, which should The Arbitrators will be receiving training on UR, which should alleviate some of the issues being experienced at this timealleviate some of the issues being experienced at this time

After care is rendered and a significant expense has been incurred After care is rendered and a significant expense has been incurred (i.e., surgical fusion) the Arbitrators and Commission often feel less (i.e., surgical fusion) the Arbitrators and Commission often feel less flexibility in denying paymentflexibility in denying payment


Utilization Review – History of Utilization Review – History of Past Models in URPast Models in UR The The past modelpast model outlined that a outlined that a

nurse could approve but not nurse could approve but not deny care--if the nurse denies deny care--if the nurse denies approval for care, the chart then approval for care, the chart then moves to a physician with a moves to a physician with a general background. general background.

If that medical expert denies If that medical expert denies care, the patient can seek an care, the patient can seek an appeal to a specialist in the field. appeal to a specialist in the field.


S&H Utilization Review – S&H Utilization Review – Considerations in W/CConsiderations in W/C S&H Medical Management believes that UR when done well, S&H Medical Management believes that UR when done well,

is a strong alternative for reviewing chiropractic or PT care, is a strong alternative for reviewing chiropractic or PT care, or based on recent cases, a strong adjunct, to an IME in or based on recent cases, a strong adjunct, to an IME in surgical cases.surgical cases.

However, why spend the time and expense for your cases to However, why spend the time and expense for your cases to go through the previous methods for a formulaic, non-specific go through the previous methods for a formulaic, non-specific UR?UR?

Do you know if your current UR provider is URAC certified, or Do you know if your current UR provider is URAC certified, or licensed in the state? (These are the two requirements licensed in the state? (These are the two requirements referenced to in the IL statutes regarding usage of UR.)referenced to in the IL statutes regarding usage of UR.)

Timing of the UR is often critical.Timing of the UR is often critical. Challenging proposed care establishes the employer’s Challenging proposed care establishes the employer’s

position and reduces the chance the worker will later be able position and reduces the chance the worker will later be able to argue the care was somehow authorized due to mixed to argue the care was somehow authorized due to mixed messages or mistaken communication.messages or mistaken communication.

When performing UR, it is essential to precisely adhere to When performing UR, it is essential to precisely adhere to the state guidelines for UR.the state guidelines for UR.


S&H Utilization Review – S&H Utilization Review – A Two Prong ApproachA Two Prong Approach

S&H Medical Management S&H Medical Management Services, Inc. has developed a Services, Inc. has developed a 2 prong approach to ensure 2 prong approach to ensure your utilization of UR is your utilization of UR is appropriate, time-sensitive and appropriate, time-sensitive and cost-effective.cost-effective.


S&H Utilization Review – S&H Utilization Review – Step OneStep One First, S&H Nurse Consultants utilize First, S&H Nurse Consultants utilize

the Medical Disability Adviser and the Medical Disability Adviser and the ACOEM Guidelines to provide the ACOEM Guidelines to provide Evidence-Based Medicine (EBM) Evidence-Based Medicine (EBM) approaches to determining approaches to determining excessive or unnecessary treatment.excessive or unnecessary treatment.

Should the injured worker be outside Should the injured worker be outside the parameters for either, a the parameters for either, a recommendation to consider UR recommendation to consider UR may be made. may be made.


S&H UR - Partnered with S&H UR - Partnered with Reviewers - URAC accredited and Reviewers - URAC accredited and State licensed!State licensed! If Utilization Review is approved, S&H can If Utilization Review is approved, S&H can

coordinate these services for our clients!coordinate these services for our clients! S&H has partnered with Utilization Review S&H has partnered with Utilization Review

companies to perform the actual URcompanies to perform the actual UR Our UR companies are URAC accredited Our UR companies are URAC accredited

and licensed to provide W/C UR in all 50 and licensed to provide W/C UR in all 50 statesstates

These companies are a truly independent These companies are a truly independent source for URsource for UR

These companies utilizes objective EBM These companies utilizes objective EBM practices and provides literature reviews as practices and provides literature reviews as part of their reportspart of their reports


Advantages of Advantages of S&H Utilization ReviewS&H Utilization Review The reviews are conducted by The reviews are conducted by

physicians the first time! physicians the first time! A definitive answer is available A definitive answer is available

regarding approval or denial, without regarding approval or denial, without having to go to the “second tier”having to go to the “second tier”

Turnaround time can be as quick as Turnaround time can be as quick as 24 hours, no later than 72 hours24 hours, no later than 72 hours

Specialists and sub-specialists can Specialists and sub-specialists can be engaged for the initial review, be engaged for the initial review, should the RN and client determine should the RN and client determine this is the best approachthis is the best approach


More Advantages of Utilizing More Advantages of Utilizing S&H as your UR S&H as your UR ProviderProvider S&H has negotiated special pricing S&H has negotiated special pricing

with our providerswith our providers Referrals are made online – again Referrals are made online – again

minimizing turnaround time!minimizing turnaround time! Questions posed to the UR physician Questions posed to the UR physician

are documented online, minimizing are documented online, minimizing correspondence expensescorrespondence expenses

Medicals can be uploaded directly to Medicals can be uploaded directly to the Review Company from the S&H the Review Company from the S&H Nurse ConsultantNurse Consultant


Process to coordinate Process to coordinate S&H Utilization Review S&H Utilization Review Referrals can be made on existing files or for cases not Referrals can be made on existing files or for cases not

currently referred to S&Hcurrently referred to S&H Upon referral the S&H Nurse Consultant quickly reviews Upon referral the S&H Nurse Consultant quickly reviews

the Medicals to ensure all needed records are available – the Medicals to ensure all needed records are available – this step is ESSENTIAL, as the easiest way to self-this step is ESSENTIAL, as the easiest way to self-destruct the reviewer is to establish during cross-destruct the reviewer is to establish during cross-examination that the reviewer did not have all of the examination that the reviewer did not have all of the medical records when he rendered his opinions*medical records when he rendered his opinions*

Any missing records are obtained from the treating Any missing records are obtained from the treating physicianphysician

A decision is then made as to type of review, i.e., Basic or A decision is then made as to type of review, i.e., Basic or Comprehensive, turnaround time required and specialty Comprehensive, turnaround time required and specialty needed, with input from the referral sourceneeded, with input from the referral source

The referral is made online, and questions are developed The referral is made online, and questions are developed by the RN, with the referral source’s input, if desiredby the RN, with the referral source’s input, if desired

* * Case Law Update – Safety National Workers’ Compensation Case Law Update – Safety National Workers’ Compensation Educational Seminar – September 15, 2009Educational Seminar – September 15, 2009


What Happens after the UR What Happens after the UR Report is Received from the Report is Received from the Provider?Provider? The Nurse Consultant receives the report through The Nurse Consultant receives the report through

an online portal on the reviewer site, and can an online portal on the reviewer site, and can immediately forward this report to the claims immediately forward this report to the claims handlerhandler

If this is the only service requested by the account, If this is the only service requested by the account, the RN will then prepare the appropriate notification the RN will then prepare the appropriate notification letters to the claimant, treating physician and letters to the claimant, treating physician and plaintiff attorney, prepare a closure letter to the plaintiff attorney, prepare a closure letter to the account summarizing results, close the file, and account summarizing results, close the file, and forward a combined invoice for RN and UR services forward a combined invoice for RN and UR services

Per recent W/C conferences, sharing the report with Per recent W/C conferences, sharing the report with the treating physician and the employee is the treating physician and the employee is essential!essential!

S&H RN services are kept to a minimum, and there S&H RN services are kept to a minimum, and there is no “up charge” when adding the UR charges to is no “up charge” when adding the UR charges to the S&H invoice.the S&H invoice.


Final considerations when Final considerations when choosing S&H for your choosing S&H for your Utilization Review NeedsUtilization Review Needs The review is coordinated by a Nurse The review is coordinated by a Nurse

Consultant experienced in workers’ Consultant experienced in workers’ compensation issuescompensation issues

The RN ensures all needed records are made The RN ensures all needed records are made available to the UR physician the first timeavailable to the UR physician the first time

Questions prepared for the UR physician are Questions prepared for the UR physician are specific to this case, not formulaicspecific to this case, not formulaic

The review is performed by a URAC accredited The review is performed by a URAC accredited company, licensed in the state for which the company, licensed in the state for which the review is performed, utilizing a physician, not review is performed, utilizing a physician, not an RN, for the initial review.an RN, for the initial review.


Thank You for Considering S&H!Thank You for Considering S&H!

Please call us at 630-226-5036 Please call us at 630-226-5036 or email us at or email us at [email protected] with with any questions.any questions.

Thank you for considering S&H Thank you for considering S&H Medical Management Services, Medical Management Services, Inc. for your Utilization Review Inc. for your Utilization Review Needs!Needs!

S&h utilization review 7 31 2014

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