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Using automation to improve outcomes. The workers’ compensation industry relies on claims examiners or bill review auditors to make a visual comparison of the approved or denied treatment to actual care rendered and mistakes are unavoidable. A more intelligent approach is through automation. (Photo: Shutterstock)

The utilization review process for workers’ compensation claims is ripe for automation. Commonly viewed as a nurse-led process, the practice of determining whether healthcare is medically necessary for an injured worker has remained relatively unchanged for decades.  Requests for authorization are submitted, a nurse compares the requested care against evidence-based medical guidelines, and a determination is issued.

The determination is a tool for the treating provider, the claims examiner, and the claimant.  Applying the determination during the actual delivery of care is traditionally accomplished by a person, typically a claim examiner or adjuster, or by a medical bill reviewer or auditor, but rarely is it done through technology-enabled automation.

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