Workers’ compensation is a system in the United States and many other countries that provides benefits to employees who are injured or become ill due to their job. State governments usually administer the program as part of social welfare programs.
One essential part of the workers’ compensation system is utilization review. Utilization review is how an insurance company or other entity reviews requests for services to determine if the services are necessary and appropriate. This article will discuss the top three things you must know about utilization review in a workers’ comp claim.
What is Utilization Review?
Utilization review (UR) is a process by which an organization reviews the use of health care services and resources. The goal of UR is to ensure that patients receive the proper care at the right time and in the right setting. UR is a critical part of ensuring that health care resources are used efficiently and effectively.
There are two main types of UR: retrospective and prospective.
Retrospective UR reviews past claims to determine whether services get provided by pre-determined standards.
A retrospective utilization review (RUR) is a quality improvement tool that helps organizations identify and correct problems using resources. The goal of a RUR is to improve the efficiency and effectiveness of resource utilization by examining past use, identifying trends, and making recommendations for change.
A RUR typically takes the form of a meeting, during which a team of analysts reviews data collected from various sources, including medical records, billing data, and pharmacy claims. The section then discusses potential areas of improvement and makes recommendations to management.
Prospective UR reviews current claims to determine whether services are appropriate for the patient and meet established clinical guidelines.
A prospective utilization review (UR) is a medical review process that is performed before services are rendered to a patient. A potential UR’s job is to ensure that the services supplied are medically essential and match the insurance plan’s regulations.
Both the patient and the provider benefit from this type of review. The patient can get assured that they are receiving the necessary care, and the provider can be confident that they are providing services that will be reimbursed.
UR typically looks at medical necessity, appropriateness of care, and quality of care.
Medical Necessity: Medical necessity is a term used in health insurance to describe the services or supplies covered by a health plan. Providers also use the time to explain the services they provide. Health insurance plans do not typically cover services and supplies that are not considered medically necessary.
Many factors determine whether a service or supply is medically necessary. These factors include but are not limited to the diagnosis, the type of service or supply, the patient’s age and medical history, and the availability of less expensive alternatives.
Appropriateness Of Care: When a patient is hospitalized, the utilization review nurse is one of the many professionals who may be involved in their care. The utilization review nurse’s job is to assess whether or not the care the patient is receiving is appropriate. It may include reviewing the patient’s chart, talking to the doctors and other health care professionals providing care to the patient, and contacting the patient’s insurance company.
If the utilization review nurse determines that the patient’s care is inappropriate, they may recommend that the patient be discharged from the hospital.
Quality of Care: One of the most critical aspects of utilization review is assessing the quality of care that has been provided. It is done by reviewing patient outcomes, as well as by evaluating the appropriateness of care processes.
What Happens If UR Finds That Services Are Not Medically Necessary?
An insurer can refuse to fund a service if it is not considered to be medically necessary. It is a case-by-case determination based on the specific services in question and the insurance plan in place. If a service is not considered medically necessary, the patient will likely be responsible for the cost of the service.
If you have further questions about UR or if you have been injured on the job, visit us at Gaylord and Nantais or give us a call at (562) 561-2669/(213) 732-3436/(805) 800-8799 to speak with a workers’ comp specialist. We can help you understand your rights and make sure you receive the benefits you deserve.