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Utilization Review in Workers' Compensation ACOEM GUIDANCE STATEMENT Utilization Review in Workers’ Compensation Review of Current Status and Recommendations for Future Improvement Melissa Bean, DO, MBA, MPH, Michael Erdil, MD, Robert Blink, MD, MPH, David McKinney, MD, MPH, and Adam Seidner, MD, MPH, and the ACOEM Utilization Review Task Force practice today. UR has influenced medical consultations, durable medical equipment Utilization review (UR) is a process that assesses care within the workers’ compensation (DME), rehabilitation, complementary and aspects of a treating provider’s care plans and (WC) system and is mandated in several alternative medicine, behavioral health care, then provides recommendations to payors/insur- 06/22/2020 on BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3JfJeJsayAVVA0tuPeWF8+fcCByaszlArA0/85mOoxJ79CzoKGQxNkw== by https://journals.lww.com/joem from Downloaded Downloaded states and jurisdictions. These mandates diagnostics, procedures, surgery, medication ance carriers, third party administrators, etc, will likely expand, placing additional chal- requests, etc, for prospective, concurrent and concerning the appropriateness of the proposed lenges on requesting providers and on retrospective reviews (see Appendix A. from care. UR has become an integral part of medical insurance carriers. Although various juris- Glossary). As discussed in ACOEM’s earlier https://journals.lww.com/joem practice and has influenced medical care within dictions implement UR regulations differ- position paper, ‘‘UR is intended to be a the workers’ compensation (WC) system and is ently, some basic principles can be applied collaborative process in which proposals to mandated in several states and jurisdictions. This to all or most jurisdictions. perform medical service for reimbursement guidance statement from the American College In 2017, the American College of are compared with high-quality, evidence- of Occupational and Environmental Medicine Occupational and Environmental Medicine based guidelines for the purpose of assuring by (ACOEM) reviews structural elements of UR BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3JfJeJsayAVVA0tuPeWF8+fcCByaszlArA0/85mOoxJ79CzoKGQxNkw== (ACOEM) developed a statement reviewing that patients receive the appropriate care programs and proposes a possible template for standards for all UR programs irrespective of necessary while avoiding ineffective, poten- operational standards. UR has a unique role in jurisdiction.1 This current paper reviews tially harmful, and low-value care.’’1 UR protecting patients and educating providers on structural elements of UR programs and looks solely at the medical necessity of a evidence-based guidelines, new research, and proposes a possible template for operational request and not at the issues surrounding best practices. standards. The standards state that UR should compensability or causation. In addition, emphasize patient welfare and proven clini- financial analysis is not typically part of tilization review (UR) has evolved cal outcomes derived from the use of trans- the peer UR reviewer decision-making pro- U into an important component of the parent evidence-based decision making cess, although these decisions may be health care system, affecting health care resulting in UR determinations that are used by the insurance carrier or bill review providers and patients and impacting med- factual, consistent with evidence-based department to approve the costs of proposed ical practice with significant implications medicine, and understandable to all parties procedures or DME. Insurance carriers for health care choices, outcomes, cost of including patients, providers, insurers, and may sometimes deny treatment based on care, and stakeholder satisfaction. Rising other stakeholders. The UR process should administrative rules including compensabil- medical costs, the desire to optimize patient incorporate oversight mechanisms, includ- ity disputes. outcomes, and the increasingly available ing quality assurance (QA) and continuous At its heart, UR is a process that options for new and complex medical treat- quality improvement (CQI) efforts, to ensure assesses aspects of a treating provider’s care ments, necessitate a process for payors to sound evidence-based treatment determina- plans and then provides recommendations to determine effective, medically necessary, tions within a timely, efficient and effective payors/insurance carriers, TPAs or UROs/ and evidence-based treatment. As a result, process. Furthermore, the perspectives of URAs concerning the appropriateness of the UR has become an integral part of medical multiple stakeholders should be incorporated proposed care. UR recommendations may be into a framework of the standards. used to authorize payment and for QA In developing standards, patient out- review. An inherent conflict exists between From the American College of Occupational and comes (emphasizing functional recovery, expediency, regulatory requirements, and Environmental Medicine, Elk Grove Village, Illinois. quality of life, and potential benefit vs harm) the time needed for thoughtful review. This guidance paper was developed by ACOEM and cost-effectiveness are considered most Another major factor for consideration is Utilization Review Task Force under the aus- relevant.2 The following recommendations the global transition from the historic prac- pices of the Council on OEM Practice. It was represent ACOEM’s public position concern- tice of medicine based upon experience to a reviewed by the Committee on Policy, Proce- on dures, and Public Positions, and approved by the ing the design, implementation, operation, more rigid evidence-based approach. 06/22/2020 ACOEM Board of Directors on February 8, and oversight of UR systems for use by all Historically, UR has been practiced in 2020. ACOEM requires all substantive contrib- stakeholders, comprised of requesting pro- many states for many years as a means to utors to its documents to disclose any potential viders, patients and/or their representatives, combat fraud, waste and inappropriate care. competing interests, which are carefully consid- ered. ACOEM emphasizes that the judgments attorneys, peer UR reviewers, employers, This often leads to improved health care, expressed herein represent the best available insurers, third-party administrators (TPAs), decreased impairment, and earlier return to evidence at the time of publication and shall utilization review agents or organizations work for the injured worker.3 Practice gaps be considered the position of ACOEM and not (URAs, UROs), regulators, policy makers, continue in health care despite well docu- the individual opinions of contributing authors. The authors declare no conflicts of interest. and researchers/academics. mented evidence-based guidelines, an obser- Address correspondence to: Marianne Dreger, MA, vation supported by examples such as ACOEM, 25 Northwest Point Blvd, Suite 700, GOALS AND OBJECTIVES OF UR worsening trends in the management of back Elk Grove Village, IL 60007 ([email protected]). SYSTEMS pain with increased use of imaging, opioids, Copyright ß 2020 American College of Occupa- tional and Environmental Medicine The purpose of UR is to review the and specialty referrals for non-specific back DOI: 10.1097/JOM.0000000000001893 safety and efficacy of treatment requests for pain while guideline supported interventions JOEM Volume 62, Number 6, June 2020 e273 Copyright © 2020 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Bean et al JOEM Volume 62, Number 6, June 2020 like physical medicine and non-steroidal procedure requested. Active practice (eg, guideline limitations, etc. When this anti-inflammatory medication use has defined number of hours performing patient occurs, the UR reviewer must thoroughly remained stable or declined.4 Evidence con- care) should be considered for a second explain their rationale for certifying tinues to mount that frequently used treat- level reviewer, especially for an appeal peer some, but not all of the requested care, ments including opioids and lumbar fusion UR reviewer. Independent organizations or for certifying a treatment outside of for degenerative disease often result in infe- that seek to improve health care quality the guidelines/criteria. This explanation rior patient outcomes or harms,5,6 and are through accreditation and oversight such for exception must be well documented thus frequently evaluated by UR. Recogni- as Utilization Review Accreditation Com- in the case file. tion of potential harm from unsupported low mission (URAC) (https://www.urac.org/) or 5. Compliance with jurisdictional require- back imaging has resulted in a call for action the National Committee for Quality Assur- ments – Jurisdictional requirements for to decrease unsupported low back imaging.7 ance (NCQA) (https://www.ncqa.org/) have peer UR reviewers vary between states Value-based health care decisions consistent recommendations pertaining to guidelines and must be followed. These criteria with evidence-based guidelines result in and reviewer qualifications. may include whether a same school, decreased costs to the carrier, the employer The proposed operational standards same or similar specialty, board certifi- and the WC system3,8 while helping to pro- for analysis of UR review request include: cation, state license, or active practice tect the worker from iatrogenic harm.9 An is required. example of this is the recent integration
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