S&h utilization review 7 31 2014

S&H Utilization ReviewS&H Utilization Review
S&H Medical ManagementS&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 theUtilization 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 yourrelated accident or condition without your
group health carrier implementinggroup health carrier implementing
utilization review.utilization review.
 If you go to a hospital or medical caregiverIf you go to a hospital or medical caregiver
for non-work-related problems, someonefor non-work-related problems, someone
somewhere is looking at the costs andsomewhere is looking at the costs and
approving what is necessary andapproving what is necessary and
reasonable.reasonable.
 Implementation of UR in non-work-relatedImplementation of UR in non-work-related
settings isn't by accident; it is donesettings 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 – RecentUtilization Review – Recent
Court Decisions in ILCourt Decisions in IL
 During the year 2011 in 23 out of 32 reported URDuring the year 2011 in 23 out of 32 reported UR
disputes, the IL WC Commission ruled contrary to the URdisputes, the IL WC Commission ruled contrary to the UR
non-certificationsnon-certifications
 In some cases there were inconsistencies noted or failureIn some cases there were inconsistencies noted or failure
to provide supporting medical recordsto provide supporting medical records
 Attention to detail could avoid easily challenged URAttention to detail could avoid easily challenged UR
reportsreports
 Under the new changes to the lL WC Act in 2011, for allUnder the new changes to the lL WC Act in 2011, for all
treatment reviewed after September 1, 2011, URtreatment 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-certificationsOf the cases upheld, the majority of the non-certifications
upheld were related to excessive chiropractic sessions orupheld were related to excessive chiropractic sessions or
physical therapy.physical therapy.
 Of the surgical cases upheld, the opinions of the IMEOf 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 URIn cases where there are strong disputes, having the UR
can be a benefit when it matches up with and supportscan be a benefit when it matches up with and supports
the position of the IME doctor.the 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 provideGive the provider a reasonable amount of time to provide
timely and complete reports of clinical information neededtimely and complete reports of clinical information needed
to support the requestto support the request
 Provide findings of the UR to the provider and employeeProvide findings of the UR to the provider and employee
 An employer may only deny payment or refuseAn employer may only deny payment or refuse
authorization on the grounds the extent and scope ofauthorization on the grounds the extent and scope of
medical treatment is excessive or unnecessary based onmedical 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 theA petitioner must establish by preponderance of the
evidence that a variance from UR standards is reasonablyevidence that a variance from UR standards is reasonably
required before treatment denied under UR will berequired before treatment denied under UR will be
awardedawarded

Utilization Review – Feedback fromUtilization 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 producethe 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 isPer the arbitrators, UR performed by a physician from out of state is
not credible – however in the new WC Act Section 8.7 the reviewingnot credible – however in the new WC Act Section 8.7 the reviewing
professional must be either available in the State of Illinois forprofessional must be either available in the State of Illinois for
interview or deposition, or be available by telephone, videointerview 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 ILIt is the employer’s burden to demonstrate to the Arbitrator and IL
W/C Commission that there are concrete standards and guidelinesW/C Commission that there are concrete standards and guidelines
that exist and to identify and explain how they impact recommendedthat exist and to identify and explain how they impact recommended
care and treatmentcare and treatment
 The Commission states UR is being under-utilized. They encourageThe 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 necessarilyGoal 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 shouldThe 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 incurredAfter 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 ofUtilization Review – History of
Past Models in URPast Models in UR
 TheThe past modelpast model outlined that aoutlined that a
nurse could approve but notnurse could approve but not
deny care--if the nurse deniesdeny care--if the nurse denies
approval for care, the chart thenapproval for care, the chart then
moves to a physician with amoves to a physician with a
general background.general background.
 If that medical expert deniesIf that medical expert denies
care, the patient can seek ancare, 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 inor 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 toHowever, why spend the time and expense for your cases to
go through the previous methods for a formulaic, non-specificgo through the previous methods for a formulaic, non-specific
UR?UR?
 Do you know if your current UR provider is URAC certified, orDo you know if your current UR provider is URAC certified, or
licensed in the state? (These are the two requirementslicensed 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’sChallenging proposed care establishes the employer’s
position and reduces the chance the worker will later be ableposition and reduces the chance the worker will later be able
to argue the care was somehow authorized due to mixedto 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 toWhen performing UR, it is essential to precisely adhere to
the state guidelines for UR.the state guidelines for UR.

A Two Prong ApproachA Two Prong Approach
 S&H Medical ManagementS&H Medical Management
Services, Inc. has developed aServices, Inc. has developed a
2 prong approach to ensure2 prong approach to ensure
your utilization of UR isyour utilization of UR is
appropriate, time-sensitive andappropriate, time-sensitive and
cost-effective.cost-effective.

Step OneStep One
 First, S&H Nurse Consultants utilizeFirst, S&H Nurse Consultants utilize
the Medical Disability Adviser andthe Medical Disability Adviser and
the ACOEM Guidelines to providethe ACOEM Guidelines to provide
Evidence-Based Medicine (EBM)Evidence-Based Medicine (EBM)
approaches to determiningapproaches to determining
excessive or unnecessary treatment.excessive or unnecessary treatment.
 Should the injured worker be outsideShould the injured worker be outside
the parameters for either, athe parameters for either, a
recommendation to consider URrecommendation to consider UR
may be made.may be made.

S&H UR - Partnered withS&H UR - Partnered with
Reviewers - URAC accredited andReviewers - URAC accredited and
State licensed!State licensed!
 If Utilization Review is approved, S&H canIf 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 ReviewS&H has partnered with Utilization Review
companies to perform the actual URcompanies to perform the actual UR
 Our UR companies are URAC accreditedOur UR companies are URAC accredited
and licensed to provide W/C UR in all 50and licensed to provide W/C UR in all 50
statesstates
 These companies are a truly independentThese companies are a truly independent
source for URsource for UR
 These companies utilizes objective EBMThese companies utilizes objective EBM
practices and provides literature reviews aspractices and provides literature reviews as
part of their reportspart of their reports

Advantages ofAdvantages of
 The reviews are conducted byThe reviews are conducted by
physicians the first time!physicians the first time!
 A definitive answer is availableA definitive answer is available
regarding approval or denial, withoutregarding approval or denial, without
having to go to the “second tier”having to go to the “second tier”
 Turnaround time can be as quick asTurnaround time can be as quick as
24 hours, no later than 72 hours24 hours, no later than 72 hours
 Specialists and sub-specialists canSpecialists and sub-specialists can
be engaged for the initial review,be engaged for the initial review,
should the RN and client determineshould the RN and client determine
this is the best approachthis is the best approach

More Advantages of UtilizingMore Advantages of Utilizing
S&H as your URS&H as your UR
ProviderProvider
 S&H has negotiated special pricingS&H has negotiated special pricing
with our providerswith our providers
 Referrals are made online – againReferrals are made online – again
minimizing turnaround time!minimizing turnaround time!
 Questions posed to the UR physicianQuestions posed to the UR physician
are documented online, minimizingare documented online, minimizing
correspondence expensescorrespondence expenses
 Medicals can be uploaded directly toMedicals can be uploaded directly to
the Review Company from the S&Hthe Review Company from the S&H
Nurse ConsultantNurse Consultant

Process to coordinateProcess to coordinate
 Referrals can be made on existing files or for cases notReferrals 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 reviewsUpon 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 theexamination 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 treatingAny missing records are obtained from the treating
physicianphysician
 A decision is then made as to type of review, i.e., Basic orA decision is then made as to type of review, i.e., Basic or
Comprehensive, turnaround time required and specialtyComprehensive, 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 developedThe 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’ CompensationCase Law Update – Safety National Workers’ Compensation
Educational Seminar – September 15, 2009Educational Seminar – September 15, 2009

What Happens after the URWhat Happens after the UR
Report is Received from theReport is Received from the
Provider?Provider?
 The Nurse Consultant receives the report throughThe Nurse Consultant receives the report through
an online portal on the reviewer site, and canan online portal on the reviewer site, and can
immediately forward this report to the claimsimmediately 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 notificationthe RN will then prepare the appropriate notification
letters to the claimant, treating physician andletters to the claimant, treating physician and
plaintiff attorney, prepare a closure letter to theplaintiff attorney, prepare a closure letter to the
account summarizing results, close the file, andaccount summarizing results, close the file, and
forward a combined invoice for RN and UR servicesforward a combined invoice for RN and UR services
 Per recent W/C conferences, sharing the report withPer recent W/C conferences, sharing the report with
the treating physician and the employee isthe treating physician and the employee is
essential!essential!
 S&H RN services are kept to a minimum, and thereS&H RN services are kept to a minimum, and there
is no “up charge” when adding the UR charges tois no “up charge” when adding the UR charges to
the S&H invoice.the S&H invoice.

Final considerations whenFinal considerations when
choosing S&H for yourchoosing S&H for your
Utilization Review NeedsUtilization Review Needs
 The review is coordinated by a NurseThe review is coordinated by a Nurse
Consultant experienced in workers’Consultant experienced in workers’
compensation issuescompensation issues
 The RN ensures all needed records are madeThe 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 areQuestions prepared for the UR physician are
specific to this case, not formulaicspecific to this case, not formulaic
 The review is performed by a URAC accreditedThe review is performed by a URAC accredited
company, licensed in the state for which thecompany, licensed in the state for which the
review is performed, utilizing a physician, notreview 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 630-226-5036Please call us at 630-226-5036
or email us ator email us at
referrals@SandHmms.comreferrals@SandHmms.com withwith
any questions.any questions.
 Thank you for considering S&HThank you for considering S&H
Medical Management Services,Medical Management Services,
Inc. for your Utilization ReviewInc. for your Utilization Review
Needs!Needs!

S&h utilization review 7 31 2014

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