It’s COMPlicated – Utility of Utilization Review 

The use of utilization review (UR) in workers’ comp has defenders and critics. Some consider UR (insurance companies and third-party administrators, et al) to  be a basic tool to prevent unnecessary medical services and reduce costs. Others (physicians and plaintiff attorneys, et al) consider utilization review to be a cause of unnecessary delays in medical care that can result in poorer outcomes and frustration for physicians and injured workers. Finding the right balance in the use of utilization review is important if the system is to provide medical care that serves the goal of effective recovery of the injured worker at a reasonable cost which serves the injured worker, employer, and society best. 

Many states authorize utilization review and usually describe it generally as a review process to ensure that medical services are medically necessary. It is hard to argue with the appropriateness of such a process. No one wants an injured worker to become addicted to drugs because a medical provider prescribed opioids for an excessively long period when the patient has chronic pain, especially if the drugs don’t result in significant improvement. Nor would anyone want a patient with back problems to have a spinal fusion with its less than impressive success rate if there were better options.  

But critics of utilization review question a process that can deny treatment considered medically necessary by the authorized medical provider or delay approval until there have been time consuming appeals. Critics complain about: 

• perceived biases of reviewers to refuse treatments for cost containment considerations 

• failure to make good faith attempts to communicate with authorized treating physicians before denying treatment 
• excessive referrals by insurance companies and third-party administrators of requests for treatment approvals to utilization review 
• practice of suddenly withholding approval of pain medications after a long history of approving the same medications and without a weaning period for a patient that is now dependent on the medications 
• denials based on an inconsequential variation from treatment guidelines 
• denials without adequate explanations of the reason for the denials 

In response to critics, utilization review organizations point to: 

• failure of physicians to adequately document the medical necessity of requested treatment 
• provision of incomplete medical files to the utilization reviewer 
• failure of physicians to respond to opportunities for peer-to-peer discussion with the utilization review physician 

So, how do workers’ compensation systems gain the advantages of utilization review with less friction and fewer negative consequences? One approach is to improve the communication flow between the physician and the utilization reviewer by: 

• inclusion of specific references to applicable evidence based medical treatment guidelines in requests for authorization of medical services and explanations of how guidelines apply to the treatment requested 
• reasonable access to peer-to-peer contact with the medical reviewer so the physician can: 

•  clarify or amplify the information sent with the request for approval of medical treatment 
• discuss the rationale for the requested treatment and the validity of the proposed treatment for the patient’s best recovery 

One solution is more fundamental for states that allow employers to provide a panel of physicians from which injured workers must choose their authorized treating physician. Employers (or their insurance companies or third-party administrators) could  choose physician panels based on quality and willingness to document requests for treatment approvals on evidenced based medicine. Then employers or their representatives could consider exempting physicians’ treatment requests from utilization review or only requiring it when physicians made requests for approval of “red flag” type treatments. Not only might this approach eliminate inappropriate delays in treatment but increase the attractiveness of providing medical care to workers’ compensation patients. 

Regulators in states that authorize utilization review can monitor the services provided in their state periodically. Reviews could include: 

• review of a random sample of requests for authorization received by the utilization review organization in the most recent twelve-month period using objective standards that apply to every organization reviewed 
• number of: reviews completed, requests for treatment approved without appeal; number denied, number approved after appeal to the utilization review provider; number approved after appeal to state regulatory agency; complaints filed against the vendor; penalties assessed by the regulatory agency.  

Solutions that improve communications and provide for transparency and efficiency in the process offer hope to retain the advantages of utilization review and minimize the friction that has been detrimental to the goal of good outcomes from medical care. A good starting place for solutions is that they follow the admonition in Hippocrates’ text Epidemics  “to do no harm.”