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.

Why automation is good for UR

Automation can have many touchpoints in the utilization review workstream. One of the first is the request intake process. Unlike bill review, the Request for Authorization (RFA) form is not standardized across the United States. Some states have very specific requirements for submitting the RFA, whereas other states offer little or no guidance on form submittal, which leads to a very manual process for data entry into a utilization review system. This is changing with new UR platforms that combine optical character recognition tools and automated intelligence or AI. The faster and more effectively that requests can be submitted for review, the sooner claimants can receive appropriate care.

The next step that is ideal for automation is the application of the appropriate evidence-based medical guideline. This includes identifying the correct criteria set, as well as the correct guideline itself. The hallmark of a good utilization review program is consistency. This includes consistency in meeting turnaround times, consistency in applying guidelines, and consistency in outcomes. Rules-based technology increases guideline accuracy. In situations where an exact match cannot be found, algorithms can serve up best matches.

Make non-certification a nonissue

Automation can also relieve delays when a treatment request is denied. Instead of waiting for the provider to submit an appeal, the noncertified case can be instantly routed to a peer reviewer for assessment. Using a peer reviewer can improve clients' outcomes when the peer reviewer is in the same specialty, has state licensure in the state where the claimant resides and has a clear understanding of the process' goals. Automating the referral process to peer review gets the case into the right hands quickly, allowing time for an effective peer-to-peer discussion.

Adding value

The dissemination of the determination is critical to communication and essential for timely management of the referral. Automating distribution is a time saver for all levels of the case. However, the biggest jump in value is achieved by tightly integrating utilization review with medical bill review.

The true value of utilization review is to establish an effective patient treatment plan that is successfully implemented. The only way to determine if this value was achieved is to close the loop between the care that was recommended and the care that was rendered. Did the provider follow the plan? Did the provider deviate from, or ignore the utilization review outcome? Did the patient follow the agreed-upon treatment plan?

Today, 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. The flaws in this approach are obvious, and mistakes are unavoidable.

A more intelligent approach is through automation. To accomplish this, the bill review and utilization review platforms need to speak the same language. Utilization review is regularly completed as a narrative and bill review reads in code. The solution is to create the request and the outcome using a medical code set that the bill review system can understand, such as CPT®, a medical code set maintained by the American Medical Association.

Brent MacLean is the general manager for Conduent's medical claims management solutions group. He leads a global team in the design and delivery of expert business process services for the company's workers' compensation clients through an expanding portfolio of solutions, including medical bill review software, clinical services and analytics. Contact him at Brent.Maclean@conduent.com.

Special Reports /

Using intelligent automation for workers' comp claims

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