Utilization Review in Workers' Compensation

UR e273 1 Practice gaps 3 At its heart, UR is a process that Historically, UR has been practiced in consultations, durable medical(DME), equipment rehabilitation, complementary and alternative medicine, behavioral health care, diagnostics, procedures, surgery, medication requests, etc, for prospective, concurrent and retrospective reviewsGlossary). (see As discussed in ACOEM’s earlier Appendixposition A. paper, ‘‘URcollaborative process is in intended which proposalsperform to to medical service be for reimbursement a are compared withbased high-quality, guidelines evidence- for the purpose ofthat assuring patients receivenecessary while the avoiding ineffective, poten- appropriatetially care harmful, and low-value care.’’ continue in health caremented evidence-based guidelines, an despite obser- well docu- vation supportedworsening trends by in the management of back examplespain with increased such use of imaging,and opioids, as specialty referrals for non-specific back pain while guideline supported interventions request and notcompensability at or the causation. issuesfinancial In surrounding analysis is addition, the not peer UR typically reviewer decision-makingcess, part pro- of althoughused these by the insurance decisionsdepartment carrier to or approve may the bill costs review ofprocedures proposed be ormay DME. sometimes deny Insuranceadministrative rules treatment including compensabil- carriers basedity on disputes. assesses aspects of a treating provider’s care plans and then provides recommendations to payors/insurance carriers, TPAs orURAs concerning the UROs/ appropriateness of the proposed care. UR recommendations may be used toreview. authorize An inherent payment conflict existsexpediency, and between regulatory for requirements,the QA and timeAnother needed major factor forthe for global thoughtful transition consideration from is the review. tice of historic medicine prac- based upon experiencemore to rigid a evidence-based approach. many states for manycombat fraud, years waste as and inappropriate a care. This means often to leadsdecreased to impairment, and improved earlier health returnwork to care, for the injured worker. looks solely at the medical necessity of a TATEMENT S SYSTEMS UIDANCE This current paper reviews 1 The following recommendations 2 In 2017, the American College of In developing standards, patient out- The purpose of UR is to review the GOALS AND OBJECTIVES OF UR ently, some basic principles canto be all applied or most jurisdictions. Occupational and Environmental Medicine (ACOEM) developed a statement reviewing standards for all UR programs irrespective of jurisdiction. practice today. UR hascare influenced medical within(WC) the system and workers’states is compensation and mandated inwill jurisdictions. likely several expand, These placing additionallenges mandates chal- oninsurance requesting carriers. Although providers variousdictions juris- implement and UR regulations on differ- including patients, providers, insurers,other and stakeholders. The URincorporate process should oversight mechanisms, including quality assurance (QA)quality and improvement (CQI) efforts, continuous to ensure sound evidence-based treatment determinations within a timely, efficient andprocess. effective Furthermore,multiple stakeholders the should be incorporated perspectivesinto of a framework of the standards. comes (emphasizingquality functional of life, and recovery, potential benefit vsand harm) cost-effectiveness are consideredrelevant. most structural elements ofproposes a UR possible template for programs operational standards. The standards state and that UR should emphasize patient welfare and proven clinical outcomes derived from theparent use of trans- evidence-basedresulting decision infactual, UR making determinations consistentmedicine, that and with understandable are to all evidence-based parties safety and efficacy of treatment requests for represent ACOEM’s public position concerning the design,and implementation, oversight of operation, URstakeholders, systems comprised of for use requestingviders, by pro- patients all and/or their representatives, attorneys, peer URinsurers, third-party reviewers, administrators employers, (TPAs), utilization review agents(URAs, or UROs), regulators, organizations policyand makers, researchers/academics. ACOEM G and Adam Seidner, MD, MPH, and the ACOEM Utilization Review Task Force Utilization Review in Workers’ Compensation 2020 American College of Occupa- ß Volume 62, Number 6, June 2020 into an important component of the tilization review (UR) has evolved Review of Current Status and Recommendations for Future Improvement Elk Grove Village, IL 60007 ([email protected]). utors to its documentscompeting to interests, which disclose are any carefullyered. potential consid- ACOEM emphasizesexpressed that herein the judgments representevidence at the the bestbe time considered available the of positionthe publication of individual ACOEM and opinions and of shall contributing not authors. ACOEM, 25 Northwest Point Blvd, Suite 700, Environmental Medicine,Illinois. Elk Grove Village, Utilization Review Taskpices Force of under the thereviewed Council aus- by on the OEMdures, Practice. Committee and Public It on Positions, and was Policy, approvedACOEM by Proce- the Board of2020. ACOEM Directors requires all on substantive contrib- February 8, tional and Environmental Medicine Melissa Bean, DO, MBA, MPH, Michael Erdil, MD, Robert Blink, MD, MPH, David McKinney, MD, MPH, Copyright JOEM The authors declare noAddress conflicts correspondence to: of Marianne interest. Dreger, MA, This guidance paper was developed by ACOEM From the American College of Occupational and U programs and proposes aoperational possible standards. template UR for hasprotecting a patients unique and roleevidence-based educating in providers guidelines, on newbest practices. research, and concerning the appropriateness ofcare. the UR has proposed become anpractice integral and part of has medical influencedthe medical workers’ care within compensation (WC)mandated system in and several states is and jurisdictions.guidance This statement from theof American College Occupational and(ACOEM) Environmental reviews Medicine structural elements of UR Utilization review (UR) is a processaspects that assesses of athen treating provides provider’s recommendations care to payors/insur- plansance and carriers, third party administrators, etc, DOI: 10.1097/JOM.0000000000001893 options for new and complex medicalments, treat- necessitate adetermine process for effective, payors medicallyand to evidence-based necessary, treatment. AsUR a has result, become an integral part of medical health care system,providers and affecting patients health andical impacting care med- practice withfor significant health implications carecare, choices, outcomes, and cost stakeholdermedical of costs, satisfaction. the desire Rising to optimizeoutcomes, patient and the increasingly available Copyright © 2020 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited Copyright © 2020 American College of Occupational and Environmental Medicine.

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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 of 1. A medical record summary – This sum- 6. Timeliness of review and decision – state pharmacy formularies with UR to mary must be sufficiently thorough, Turnaround times (TAT) are critical reduce inappropriate prescribing, including accurate, and include documentation and must be met. This varies based on opioid use.10–12 of all the pertinent clinical, diagnostic, the jurisdiction and decision delays or Recent research has acknowledged therapeutic, and other important facts of improper processing of the determina- that it may take several years for physicians the case including any red flags, poten- tion may be subject to state fines, poten- to adopt new evidence-based medical treat- tial exceptions to guidelines, or ratio- tial denial of the request (Texas), or ment plans and abandon ineffective historic nale for care requests. This summary approval of the request (California). treatments. One example of this type of must also include pertinent negatives TAT for UR should be clearly stated persistent behavior is the continued high identified in the medical record. and understood by all participants. This rates of treatment of degenerative meniscal 2. Application of evidence-based medicine facilitates timely decisions and execution tears with arthroscopy despite the lack of – The application of evidence-based of care plans. Of high significance is that evidence of efficacy in the majority of medicine must be documented, including there is an injured worker at the ultimate cases.13–15 New technology and innova- the specific criteria utilized and how it receiving end of any decision to approve tions, while much-needed in health care, relates to the individual clinical facts of or deny a treatment, and therefore exces- oftentimes do not meet the rigorous clinical the case. This should result in a clear sive administrative delays should be standards for efficacy to truly improve determination with sound reasoning and avoided. patient outcomes or to establish benefits obvious and defensible rationale. 7. Appeals – Physician appeal reviews exceeding harm. For example, intradiscal 3. Requesting provider and peer UR must be performed by an independent electrothermy (IDET) to treat ‘‘discogenic reviewer discussion – The requesting (eg, absence of financial interest; mate- pain’’ continued long after evidence includ- provider and the peer UR reviewer rial personal, professional or business ing a sham randomized controlled trial and should directly discuss the facts of the relationship; prior involvement with the subsequent guideline recommendations con- case and the criteria applied when case), board certified physician within cluded the lack of efficacy.16,17 UR has a denial or only partial certification of the same or similar specialty, and with unique role in protecting patients and edu- care is being considered. The UR sys- adherence to jurisdictional require- cating providers on evidence-based guide- tem must provide reasonable opportu- ments. Non-physician (non-MD/non- lines, new research, and best practices. nity for the requesting provider to DO) appeal reviews, where board certi- discuss his/her findings and treatment fication is not a requirement (eg, chiro- QUALIFICATIONS plan with the peer UR reviewer. The practic, acupuncture, psychology, etc), The UR determination corresponds peer UR reviewer and the requesting should be conducted by practitioners to the qualifications of the peer UR provider share responsibility for making who are independent (including not reviewer. At every level of review (eg, the peer-to-peer contact occur (see sec- reporting to the peer UR reviewer 1st, 2nd, 3rd, independent medical review tion on UR Decisions and Stakeholder who rendered the non-certification deci- [IMR], independent review organization Responsibilities). sion under review), are not financially [IRO]), the reviewer must have an appro- 4. Flexibility for unusual circumstances – associated with the requesting treater, priate level of expertise (eg, education, Occasionally cases require complex have the appropriate level of training, training, licensure, certification, experi- decision making that justify treatment licensure, expertize, and who adhere to ence, scope of practice, jurisdictional that is not supported by evidence-based jurisdictional requirements. requirements, etc) to understand and opine medicine or specific guideline criteria. on the clinical issues involved and applica- These scenarios may include uncommon CREDENTIALS ble guidelines. Peer UR reviewers should cases or treatments, cases with compli- Credentialing of the peer UR demonstrate understanding and compe- cations or an unusual clinical course, reviewer should include primary source tence regarding the clinical circumstances previous documented response to the verification of education and training, but also the regulatory and administrative requested treatment or current updates active board certification, licensure, disci- requirements of the jurisdictional UR sys- in evidence-based literature and research plinary actions, malpractice history, and tem. Consideration should be given to the not reflected in applicable guidelines. adequate liability insurance coverage to specialty and scope of practice of the Peer UR reviewers may, at times, recom- include omissions and errors. Validation requesting provider and utilize a similarly mend modified certification based upon of active practice is important when juris- qualified reviewer. The reviewer must have specific circumstances, including prior dictionally required. Re-credentialing at a detailed understanding of the treatment or positive response to care, comorbidities, regular 2 to 3 years intervals is commonly

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Copyright © 2020 American College of Occupational and Environmental Medicine. Unauthorized reproduction of this article is prohibited JOEM Volume 62, Number 6, June 2020 Utilization Review in Workers’ Compensation

required. Policies and processes should be must be based on accurate information, to the guidelines. An agent may be in place for removal of peer UR reviewers correct assessment of the medical informa- helpful in setting up the provider inter- that are unable to meet credentialing or QA tion, and application of evidence-based action and in obtaining missing medi- standards, including TAT. Payments to peer guidelines. No UR preauthorization treat- cally necessary documents prior to the UR reviewers must not be based on targets ment requests should be denied or partially peer-to-peer conversation but relying for specific determinations or denial (non- certified/modified without satisfying a list exclusively on this involvement does certification or partial certification) rates of requirements: not satisfy the requirement for peer- that are not supported by medical facts to-peer contact. The WC system should and applicable evidence-based guidelines. 1. Only a physician or appropriate equiv- make all reasonable efforts to encour- alent peer depending upon the nature age and incentivize both reviewing and PEER REVIEWER ORIENTATION of the request and jurisdictional requesting physicians to successfully AND TRAINING requirements (such as a chiropractor, accomplish and conduct a collegial, UR agents must provide effective and dentist, psychologist, acupuncturist, high-quality, fact-based peer-to-peer efficient orientation, training, oversight, and physical therapist, occupational thera- interaction and educational discussion. monitoring to ensure appropriate peer UR pist, etc) should recommend denial or This interaction is typically conducted reviewer performance. UR organizations modification (partial certification) of a via one or more confidential telephone operating in jurisdictions that mandate spe- UR request (2nd and 3rd level review). conversations. However, if both the cific UR regulations and guidelines are In the majority of states, nurses, nurse reviewing and requesting physician responsible for providing clarity in the regu- practitioners, pharmacists, physical/ agree, the information may be transmit- lations promulgated and assurance that ade- occupational therapists, or other health ted via other secure electronic means or quate training is available to reviewers for the professionals performing first-level fax where permitted by regulations and policies and guidelines mandated. Training review cannot deny UR requests or in full compliance with all applicable should include jurisdictional requirements for pharmacy requests. (One exception is laws including HIPAA18 and informa- UR and instruction in navigation of the elec- Massachusetts’ state regulations which tion technology (IT) security compli- tronic health record (EHR) system including require school to school matching for ance statutes. any portals used for access to medical records second- or third-level peer UR review.) a. Both the requesting provider and the and transmission of UR reports back to the 2. First-level nurse UR reviewers must peer UR reviewer have responsibil- UR organization or agent. The orientation understand jurisdictional requirements. ities to complete and improve the should also cover the importance of electronic These professionals must have access to peer-to-peer process. A successful data security, confidentiality of injured a secure portal and tools for an efficient UR interaction is most effective worker information, conflicts of interest, process to prevent unnecessary delays when all appropriate documents proper use of technology including portals, in UR response causing delays in supporting the request are available. documentation and tracking of phone calls, injured worker care. Proper documen- This is ultimately the requesting conduct of peer-to-peer conversations, and tation, security and confidentiality are provider’s primary responsibility. access to guidelines and medical documents. important. If approval cannot be made The peer UR reviewer may also Reviewers must also be instructed on elec- by the nurse based upon review of greatly enhance the likelihood of tronic security, avoidance of conflicts of inter- medical documentation versus evi- successful communication by est, Health Insurance Portability and dence-based criteria or required guide- attempting to contact the treating Accountability Act of 1996 (HIPAA) confi- lines, then the review must be provider during the provider’s reg- dentiality of patient information,18 and avoid- forwarded to the peer UR reviewer ular office hours or when the ance of any appearance of bias. without delay. Rapid response is impor- requesting provider has indicated All complaints should be investigated, tant to allow time for the peer-to-peer their availability. The peer UR resolved, and tracked. Recurrent complaints conversation and return of the determi- reviewer should also leave clear should receive more in-depth analysis and, if nation within jurisdictional time phone contact information includ- necessary, corrective action. Policies must be frames. The nurse should try to obtain ing hours of contact for the treating in place to address the process and outcomes any medically necessary reports or pro- physician to call as well. When of complaint investigations. The UR review cedural results that are important for both physicians understand the time process should be improved based on infor- making the determination. The UR constraints, maintain flexibility, mation gleaned from complaints from any nurse should initiate requested recon- availability, and the willingness to party, including requesting provider, patient siderations or appeals and forward any participate in the UR process, the or their attorney, claims adjuster, UR nurse or complaints to the appropriate depart- best outcome for the injured worker nurse case manager, peer UR reviewer, state ment for review and resolution. can be achieved. The treating phy- or accrediting body. 3. The UR system must provide reason- sician is in direct contact with the able opportunity for the requesting injured worker and is responsible provider to discuss his/her findings for the medical care of his or his UR DECISIONS AND and treatment plan with the peer UR patient. The peer UR reviewer is STAKEHOLDER reviewer. This exchange of informa- responsible for thorough review of RESPONSIBILITIES tion should occur before recommend- the clinical medical records, and Accountability is the foundation for ing a denial or partial certification. The documented application of specific appropriate utilization management. UR purposes of this dialogue are to: (1) evidence-based medical guidelines, participants and their roles should be obtain any missing information; (2) with a clear explanation of the rec- clearly identified at every step. To improve discuss the rationale for the request; ommendation including guideline transparency, the peer UR reviewer for each (3) explore the expected outcomes criteria that were not met for partial determination should be identified by versus risks; (4) evaluate congruence certification or denial. Likewise, name, school, specialty, board certification, with applicable guidelines; and (5) clinical determinations that are and licensure. Appropriate determinations investigate rationales for exceptions approved should also be supported

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by evidence-based guidelines and referrals from the requesting physi- evidence-based medicine (strength of rationale for feedback to all neces- cian or a history of a significant past evidence). Reviewers should identify sary stakeholders (ie, the provider, legal dispute between the peer UR if there is adequate rationale to apply injured worker, insurance carrier, reviewer and the requesting pro- exceptions to the guidelines’recommen- URA or URO, attorney, state regu- vider. dations. lator) and for future quality assur- e. The cooperation and collaboration 5. Denials or modification (partial certi- ance review. The peer UR reviewer by both requesting providers and fication) should specify the guideline has no direct contact with the peer UR reviewers should be and criteria that were not met to permit injured worker and no patient–phy- tracked and appropriate interven- the provider to appeal/rebut the denial sician relationship is established. tions implemented as needed and and to educate the requesting provider This concept was recently litigated where permitted by applicable juris- regarding expectations and evidence, in California where the state medi- dictions or networks. Examples of including appropriate application of cal board opined that UR is the interventions include retraining, evidence-based medical guidelines. practice of medicine. Tort action review of policies and procedures 6. Clinical situations not covered by was initiated and lower courts with increased monitoring of com- guidelines should be evaluated by thor- awarded damages based upon peer pliance and removal from review or ough assessment of objective evidence UR recommendation to deny care, provider networks if indicated, etc. from submitted documentation, with subsequent reversal of the deci- f. Criteria to subject treatment including the claimant’s prior response sion by the California Supreme requests to UR should be carefully to the treatment requested, consider- Court based upon WC being the determined to maximize system ation of other pertinent clinical knowl- exclusive remedy for employees benefits and outcomes, minimize edge and guidelines, and review of with work injuries, thereby pre- treating provider burdens, and related evidence-based medical litera- empting tort claims (such as mal- avoid unnecessary care delays ture. Another possible consideration is practice associated with utilization and excessive administrative costs. the consistency of the treatment review).19 The criteria development should request with other medical treatment b. While monetary costs may be used consider factors such as emergency specialists evaluating the claimant. to determine when UR triggers care, timing of care and compli- 7. All determination notifications must (referral to UR review), medical ance with evidence-based guide- be clear, timely, and meet jurisdic- UR determinations must be based lines, risk versus benefit, tional requirements. Systems should on review of clinical efficacy and expected or demonstrated out- strive to avoid delays or gaps in sup- assessment of benefit versus risk or comes, duration of treatment and ported care. All parties should remain the requested medical service or the need for skilled versus self- cognizant that there is an injured treatment. Outcome measurements care, high versus low value care worker at the heart of the process. should be tracked for improvement requests, and experimental treat- Unnecessary delays in rendering an of both clinical quality and func- ment requests. Some suggested appropriate determination are poten- tioning of the UR system itself, options include: tially detrimental to that worker’s thus serving all stakeholders (see i. Recommendation for approval treatment, delaying recovery and section on Outcomes and Metrics). without UR review: Examples return to work, and ultimately increas- c. Implementation of a UR system include emergency care consis- ing WC system costs. must protect patient confidentiality tent with guidelines, acute and 8. The appeal (also IRO or IMR) and while operating transparently to time limited treatment trial jurisdictional options and process foster acceptance of the process, involving conservative care should be specified in writing when allow identification of bottlenecks consistent with guidelines. providing decisions with a denial or and maximize opportunities for ii. Recommendation for UR modification (partial certification). continuous quality improvement. review: Requests for experi- The peer UR reviewer should under- d. Any conflict of interest or the mental treatment, lack of evi- stand the appeal process and educate appearance of such, must be dence-based support, care the requesting provider as needed. avoided at every stage in the UR exceeding treatment guidelines The appeal, IRO or IMR process out- process. Incentives based upon with limited efficacy, invasive comes should follow quality standards denials/modification (partial certifi- treatment including surgery, for reviewer qualification and decision cation must be avoided/precluded). hospitalizations, treatments rationale and documentation. Any URO/URA and peer UR review with evidence of suboptimal deficiencies present in the original policies and procedures must man- outcomes or potential risk request and UR recommendation must date that if the peer UR reviewer exceeding benefits. be meticulously evaluated during the identifies a potential conflict of 4. All decisions should follow a medically formal IMR/IRO review. interest upon receiving a case, then logical approach, document the ratio- 9. Physicians who understand clinical cir- the peer UR reviewer must notify nale for the decision, be supported by cumstances in WC cases, as well as, the the sender and not accept the case. clinical information with consideration application of guidelines and jurisdic- UROs/URAs should try to identify of applicable guidelines or evidence- tional variations in regulations should and avoid potential conflicts of based literature where applicable. be involved in: the routine quality assess- interest prior to assigning a peer Denial or modification (partial certifica- ment of the UR process; peer review UR review case. Examples of con- tion) must be based on objective review determinations; appeals; and orientation, flicts of interest include a peer UR of submitted documentation, peer-to- training and retraining of peer UR reviewer that works in the same peer discussion when possible, risk reviewers when issues are identified. practice as the requesting physician, versus benefit, applicable guidelines, 10. Claim representatives must understand a peer UR reviewer that receives and/or an identified hierarchy of jurisdictional rules and be accessible to

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injured workers and claims managers. guide effective clinical decision-making and utilization management, then that state Adjusters must prioritize UR proce- ensure the consistent use of proven medical guideline takes precedence over any other dural, medication or treatment requests evaluation and treatment. It can also reduce guidelines and must be referenced and to prevent unnecessary delays in care. medical interventions or treatments that can applied first in any UR review. However, 11. Attorneys should understand and fol- make injured workers worse. Adherence to these guidelines often vary in the detail, low the jurisdictional UR processes the ACOEM Practice Guidelines8,23 or Offi- adaptability, and medical appropriateness and appeals. They should facilitate cial Disability Guidelines (ODG by MCG)24 of the medical decision making provided. allowed information flow between par- have demonstrated a significant difference in The states, UROs/URAs, and carriers ties to encourage early injured worker claims outcomes resulting from adherent should strive for the use of the best guide- recovery and return to work. care. (See section on Research Findings lines permitted so that appropriate determi- Regarding UR.) nations are supported. GUIDELINES AND EVIDENCE- Many jurisdictions have adopted the Treating provider and peer UR BASED MEDICINE use of evidence-based medicine guidelines reviewer use of guidelines will depend on Guidelines are important in utiliza- in their WC systems. WC claims that follow their ease of use and access, as well as, their tion management in setting standards of evidence-based medicine guidelines have clarity. When the requesting provider under- medical care, consistency in decision mak- shorter durations and lower medical costs. stands and properly applies the guideline ing, and clarity of rationale for decisions. Research supports improved outcomes and during medical decision making with an Guidelines must be based on high-quality, cost savings when medical providers follow injured worker, there is less need for peer evidence-based medical research (Table 1) recommendations based on peer-reviewed UR reviews and appeals, since the guideline that is nationally accepted and applicable to evidence in WC treatment guidelines.3,8 would correctly support the medical deci- the condition and requested intervention. It is important to acknowledge that sions and allow for first level (nursing or The guidelines must be clearly acknowl- situations arise in clinical medicine by automated) approval of requests. If there are edged and available to all stakeholders for which strict application of evidence-based repeated denials for the same diagnostic test transparency, ease of use, and application. medical guidelines may not result in the or treatment, then an educational discussion Guidelines may outline appropriate medi- optimal clinical outcome for the patient. with careful review of the requesting pro- cal treatment plans and decisions (eg, phar- Understanding the nuances of the particular vider and peer UR reviewer interpretation of macologic, rehabilitation, interventions, case is vital. Thus, there needs to be an the guideline should be undertaken along surgery, experimental treatment), the dura- understanding by stakeholders that there with a plan for additional training and clar- tion of medical care (eg, physical or occu- will undoubtedly be exceptions to UR sys- ification of the process and guidelines. Med- pational therapy, chiropractic care, etc), and tem guidelines. The exceptions must be ical treatment guidelines should be current length of hospitalization. Guidelines may carefully explained and supported by the with at least annual review or update. also reference functional improvement or clinical facts of the case, for example, The structure (including use of UR) lack thereof. The evidenced-based medical comorbidities, severity of injury, delays and implementation of formularies26 is hierarchy of evidence should be specified in care or past functional response to treat- challenging, and still under development for use by the system and/or jurisdiction. ment that is well documented. in several jurisdictions (International Asso- Guidelines must be based on a complete Orientation and training courses on ciation of Industrial Accident Boards and review of evidenced-based medical sources the content and proper application of guide- Commissions [IAIABC] 201627 and 201928 with ranking of the sources and a clear and lines should be made available to providers reports regarding status of state WC formu- precise interpretation of how guidelines and peer UR reviewers. An example of laries). From a clinical point of view, should be correctly and appropriately training outreach is available from the Cal- urgently needed pharmaceuticals need not 20,21 22 applied (eg, AGREE II, GRADE, etc). ifornia Department of Industrial Relations be denied or unreasonably delayed, just as Evidence-based medicine can Physician Education module on the use of with other aspects of medical treatment; but decrease excessive, unnecessary, and poten- the Medical Treatment Utilization Sched- with medications there is often no way for a 9 tially harmful medical care. Studies have ule.25 Many states have made their guide- caregiver to provide necessary medications shown that evidence-based medicine guidelines available on the internet for easy prior to receiving authorization. For that lines can raise the quality of care. Evidence- access at no or low cost. If the state has reason, structure and implementation of based medicine uses scientific studies to help selected a specific state guideline for WC such systems require care to provide rapid

TABLE 1. Quality of Evidence

Evidence Level Types of Studies or Evidence

Higher grade of evidence Systematic reviews: structured reviews including meta-analysis with summary of studies looking at study design, quality, bias, confounding, outcomes resulting in a higher level of evidence recommendation on the effectiveness of health care interventions. Randomized controlled trials: studies in which patients are randomly assigned to treatment and control groups. High- quality, prospective randomized controlled trials with low risk of bias are preferred. Prospective cohort studies: forward observations of groups of patients over time and comparison of characteristics and treatments. High-quality studies with low risk of bias are preferred. Retrospective cohort studies: similar studies looking back at previously collected data. High-quality studies with low risk of bias are preferred. Lower grade of evidence Case–control studies: matching people with a health problem to other people with similar characteristics, but without the health problem, are regarded as less accurate. Case reports (multiple) with no match or control group Individual case reports Expert opinion including other treatment guidelines, textbook, conference proceedings

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provision of urgently needed medications medical director (MD, DO). The qualifica- complaints in a timely manner. Any com- via some combination of rapid-response tions of the medical director include a plaints, including reported concerns from UR, and/or a list of pre-approved (eg, strong background and broad understand- the treating or requesting provider, should exempt) medications that can be dispensed ing of work-related disorders, clinical med- be discussed with the peer UR reviewer and when consistent with guidelines prior to icine, evidence-based medicine, and allow the peer UR reviewer to explain the retrospective UR or without UR at all. utilization management. It is important that basis for any decision or extenuating cir- the medical director be actively involved, cumstances involving the clinical facts or OVERSIGHT have the ability to analyze quality data and discussion with the requesting provider, Active oversight and intervention by implement corrective action plans and pol- including courtesy and professionalism. all parties is required to improve outcomes, icies to drive positive change in the UR There must be a process for feedback to system efficiency, quality, and stakeholder system. Objectivity and good communica- the treating or requesting provider with satisfaction. Appropriate systems should be tion skills are vitally important for this documentation and tracking of complaint implemented to provide oversight for juris- physician when working with and educat- resolution. A similar process should apply dictional elements such as TAT, reviewer ing diverse stakeholders and colleagues. to tracking and resolution of any complaints qualifications and licensure, IRO or IMR A multidisciplinary team should be regarding courtesy and professionalism of decisions, and complaints, up-to-date peer created to review the entire UR process. treating or requesting providers. It is often UR review contracts and liability coverage. Each UR agent should have an internal important to allow the appeal process to A comprehensive oversight plan contains QA process that addresses clinical quality proceed simultaneously with investigation multiple components and processes to measures and includes reasonably sized ran- of the complaint so that the jurisdiction TAT ensure compliance, reasonableness, and dom quality review of UR decisions by a is respected. Timeliness is required by the system continuous quality improvement. physician and/or other qualified health care overarching system structure; this is State audit programs, URAC or NCQA professional peer who is appropriate for the intended to give feedback to the reviewer provide external oversight of internal pro- QA setting (eg, chiropractor, psychologist, as to how well they did in independent cesses to assure compliance. Vendor man- etc). Peer UR reviewers should be indepen- audits. Accuracy (eg, avoidance of errors, agement processes and oversight are dent and without conflict of interest, or in the reports without inconsistencies), correct critical to ongoing success. Electronic algo- situation of an appeal, they should not have understanding of the case, application of rithms for automatic approval of initial UR been involved in the case’s initial UR pro- clinical information with references to requests should be based on evidence-based cess. If services are vended, then there applicable guidelines, good decision mak- medicine and reviewed regularly for cor- should be a QA review and oversight of these ing, percent of cases with good faith peer- rectness, outcomes, and necessary updates. services. Results of this URA/URO QA pro- to-peer contact attempts, and successful Complex or prolonged cases, higher risk, or cess should be evaluated on a periodic basis peer-to-peer calls, are all measurements experimental procedures must have direct (system wide, by reviewer and requesting that should be collected. oversight and review. physician) and result in appropriate inter- It is essential that the system of UR ventions where indicated based on QA defi- INFORMATION MANAGEMENT, in WC integrates QA elements into its ciencies. Results of the UR agent QA process SECURITY, AND structure and is applicable to the treating must be communicated to the reviewing CONFIDENTIALITY physician, the reviewing entity and its physician with attention to improving his/ Professionals shall conduct UR con- agents, and the UR system itself. For effec- her performance (eg, corrective action plan). sistent with the jurisdictional regulatory, tive QA and CQI, there must be the collec- More frequent monitoring of cases should be licensing, credentialing, and insurance laws tion of appropriate metrics, a rational and implemented when appropriate. and rules as well as national standards. fair procedure to assess quality, a feedback Quality assessments should include Credentialing by independent organizations mechanism to both educate the participants review of the clinical information provided, like URAC or NCQA is desirable to pro- as to their successes and to any needs for decision appropriateness, guideline promote compliance with high level QA stand- improvement, and a system flexible enough vided, proper selection of the reviewer ards. UR professionals should ensure that to efficiently implement changes where based on scope of practice, board certifica- workspaces are secure and private (eg, pol- needed (see Outcomes and Metrics). tion, and jurisdiction requirements. Quality icies and procedures with effective training, Oversight should demonstrate the review of appeals should include review of restricted access to worksite, secure com- monitoring and evaluation of quality of the clinical records and initial determina- puters and information technology system, UR, as well as, the quality of care, service tion that denied the request with a compar- strong computer passwords, locked access concerns, complaints and grievances, ison of the appeal determination and to sensitive information, confidential con- patient rights, adverse/critical events, safety appropriateness of the rationale for any versations, liability coverage, and rapid issues, and UR processes consistent with uphold or overturn to appeal decision. responses to data breaches, etc). jurisdictional and contractual network Jurisdictions should have clear guide- Backup systems are necessary and requirements. This is accomplished through lines and ease of access, offer frequently should involve a set of policies, tools, and the systematic and consistent application of asked questions (FAQs) to improve consis- procedures to enable the recovery or con- utilization management processes based on tency or system participants, implement tinuation of vital technology infrastructure current, relevant medical review criteria, mechanisms to monitor provider quality of and systems following a disaster. Disaster and expert clinical opinion when needed. care concerns from patients and UR agents recovery planning is an integral part of any UR agents should track timeliness of the and implement interventions where indi- UR service. A good plan will cover all completion of a peer view, TAT, reviewer cated, systems to monitor complaints regard- potential scenarios. Disaster recovery qualifications and training, inter-rater reli- ing UR agents and peer UR reviewers and requires the determination of the recovery ability of determinations, complaint review implement interventions, monitor quality of time objective in order to designate the and management, and percent of times a IRO or IMR decisions and implement inter- maximum amount of time the business peer UR reviewer is successful in contact- ventions. can be without IT systems post-disaster. ing requesting providers. Final oversight of UROs/URAs, networks and jurisdic- The ability to meet a given recovery time these measures should be conducted by a tions must implement systems to address objective requires at least one duplicate of

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the IT infrastructure in a secondary location OUTCOMES AND METRICS requirements for certain practitioners who to allow for replication between the pro- comply with network policies and proce- duction and disaster recovery site. The UR process requires continuous dures, use evidence-based practice (eg, The purpose of the HIPAA Privacy or periodic assessment to determine if pro- adherence to appropriate use criteria or Rule is to allow the safe transfer of medical gram goals are being achieved. Desirable clinical decision pathways, evidence-based information from one health insurance goals for UR systems include contributing guidelines, etc), and have demonstrated company to the next, and from one health to patient recovery and return to work, better outcomes. In return, preferred pro- care provider to another.29 The HIPAA promoting reasonable and necessary care viders can reduce administrative burdens Privacy Rule was finalized in 1999, and it delivered in a timely manner, avoiding and potential delays of care, improve effi- requires safeguarding of patient informa- ineffective or unnecessary and potentially ciency, and satisfaction. tion against unauthorized access and dis- harmful treatments, promoting high versus As noted, quality improvement closure. In 2003, the HIPAA Security Rule low value care (ie, cost-effective care), and requires assessment of outcomes metrics, was published and subsequently the HIPAA maintaining stakeholder satisfaction. comparison to evidence-based medicine Enforcement Rule and Breach Notification This assessment of system efficacy, and best practice, and implementation of Rule,30 all in an effort to keep up with impact, or harm requires development of strategies to improve outcomes. A compre- technology and meet the demand of patient meaningful and measurable outcomes met- hensive list of outcomes metrics that each privacy. In the WC arena this means obtain- rics. Organizations need to dedicate ade- stakeholder should track is beyond the ing and securing medical information quate resources and involve appropriate scope of this paper. Each stakeholder needs within the HIPAA rules. Individuals have personnel including senior management to to perform an analysis to determine which an interest in privacy, but in the context of achieve success in this activity. Determina- outcomes metrics best meet their unique WC, that privacy right recognizes an tion of the specific metrics for various enti- circumstances, goals and responsibilities. employer’s legitimate business interest. ties to measure will vary depending upon the However, recognizing some of the key HIPAA’s Privacy Rule allows WC insurers, goals, roles, and responsibilities of each goals for the UR process listed above, some TPAs, and some employers to obtain the stakeholder. In order to achieve system-wide suggestions for system participants to con- necessary medical information to manage quality improvement and collaboration, sider are worth mentioning. their WC claims. these metrics should be reasonable and WC carriers and administrators typi- reflective of key program goals and quality Utilization Review Agents cally send authorization release forms to components, easily measured, transparent URAs are entities that conduct UR injured employees upon the receipt and ini- and reported in an understandable format. for medical necessity and appropriateness tiation of a WC claim to ensure compliance Stakeholder quality performance needs to be of health care services on a prospective, with HIPAA and state laws. Covered entities measured and tracked on a continuous or concurrent, or retrospective basis. URAs are required to reasonably limit the amount sufficiently frequent periodic basis (eg, quar- perform UR for number of stakeholders of protected health information disclosed. terly) to ensure maintenance of quality and including payers, employers, TPAs, etc. Disclosure of medical information can vary offer opportunity for timely quality improve- URAs are responsible for assuring timely from state to state, and in some instances, ment. Results need to be carefully analyzed decisions to facilitate delivery of high qual- you do not need a medical release/authori- to determine if meaningful quality metrics ity, cost-effective care. URAs need to effec- zation whereas in others you do. The Privacy are being achieved. If not, adopted metrics tively communicate and collaborate with Rule for Workers’ Compensation is designed should be subject to root cause analysis, and health care providers to improve the UR to provide the minimal necessary informa- used to provide useful feedback to system process and knowledge of evidence-based tion needed to manage a claim and should participants as part of the process of devel- medicine including clarification of guide- comply with privacy standards. oping action plans to address quality defi- lines or evidence-based criteria used. URAs UR professionals must be aware of ciencies (including education, policy, must adhere to regulatory requirements and the various jurisdictional rules. In Califor- procedural change, and monitoring to pre- performance standards for UR. Continuous nia, the Confidentiality of Medical Infor- vent recurrence). The analytic process eval- quality improvement with implementation mation Act (CMIA) protects confidentiality uating metrics should determine if there is a and updates of operational process, poli- of medical information limiting where the need to periodically revise quality targets to cies, and programs are necessary on an release of medical information is permissi- further improve performance and outcomes, ongoing basis. Examples of relevant met- ble.31 In Illinois, state privacy laws in WC to assess if there is a need to adopt new rics include: require a consent to release information and metrics or if some measures no longer the self-insured employer, carrier or claims require tracking due to the effectiveness of 1. System wide rates of timeliness. administrator has the right to the medical designed and implemented system policies 2. Determination outcomes including records in order to pay benefits. In Ken- and procedures. approvals, partial or modified appro- tucky, if an employee files a WC claim, the Redundancy, duplication, and exces- vals, denials. employee is required to sign a waiver and sive paperwork can be a significant barrier to 3. Rates of appeals and appeal overturns, consent related to the injury being claimed efficient UR. An effort should be made to including appeal through the URA (ie, so medical records can be obtained. facilitate efficient review of the relevant third level review), or jurisdictionally Sharing of sensitive genetic informa- clinical information wherever possible and designated external entities conducting tion is covered by The Genetic Information reduce the burden on requesting providers to reviews after appeal denial by the URA Nondiscrimination Act of 2008 (GINA).32 repeatedly submit the same documentation. (IMR or IRO). GINA states an employer may never use Software is available that can scan docu- 4. Successful peer-to-peer contact rate genetic information to decide employabil- ments and tease out redundancies. These (with identification of root causes of ity or any aspect of employment. It also are not widely used, but improved efficiency lack of contact). prohibits employers from intentionally could result in systematic cost savings. 5. Regulatory compliance. obtaining such information. A UR reviewer ‘‘Outcomes based networks’’ or 6. Results of reviewer QA audits including must be aware that information covered by ‘‘Preferred provider status’’ may allow first, second, and third level reviewers GINA must be handled properly. exemption from or reduction of UR and any sub-vendors; description of

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audited components and who performs 1. Credentialing report with status of con- status of UR decisions in WC and what is quality audits; interrater reliability; tracted providers (training, licensure, known with respect to the ability of UR to interventions for reviewers who do board certification, specialty, disciplin- achieve quality outcomes and cost control not meet quality metrics. ary actions including termination). goals in order to justify these programs. 7. Complaints (including the source and 2. Provider quality measures including Since UR involves a determination that focus of the complaint) and resolution patient outcomes and return to function applies medical facts versus evidence-based of identified issues. including work. guides, the quality of guidelines is critically 8. Maintenance of confidentiality includ- 3. Patient safety issues. important and knowledge of the effect of ing any breaches and resolution. 4. Complaints (including complaints from adherence to treatment guides on outcomes 9. Satisfaction (including that of patients patients, hospitals and healthcare set- should be evident. In addition, observations and of treating providers). tings, insurers, URAs), and resolution regarding any known or potential adverse of identified issues. impacts of UR merit discussion. Further- Peer Review Organizations 5. Provider collaboration and adherence to more, there is a need to understand potential PROs are independent entities that network policies and procedures includ- alternatives to the current UR system and perform UR review for URAs using quali- ing behaviors suggestive of potential research needs to better identify UR benefits fied physicians and other appropriate health system abuse (eg, excessive rates of versus harms and improvement opportuni- care providers. PROs need to ensure that IMR/IRO requests, unsupported care). ties in a variety of WC systems. reviewers effectively communicate and col- A recent ACOEM position paper laborate with health care providers to Jurisdictions discussed a number of challenges facing improve the UR process (including enhanc- Jurisdictions include the federal sys- the United States health care system including successful peer-to-peer conversations) tem, states, and other regulatory UR entities ing rising costs of health care and disability, and provider knowledge of evidence-based (eg, Longshore Act). Jurisdictions define less optimal outcomes and cost-efficacy in medicine and guidelines or review criteria. regulatory requirements for all stakeholders comparison to several other countries, over- PROs must adhere to regulatory require- involved in the UR process. Examples of reliance on fee for service, lack of care ments and performance standards for UR in relevant metrics include: coordination, and failure to focus on longer addition to adopting continuous quality term outcomes including functional improvement procedures. Examples of rel- 1. Any specified regulatory guideline cri- improvement.2 Another study suggested evant metrics include: teria. that estimates of unnecessary medical 2. Results of appeals conducted by IMR or spending for low-value care could range 1. Credentialing report with status of peer IRO including submission rates, timeli- from 6% to as high as 29%.33 There are UR reviewer panel (training, licensure, ness, rates of overturns by service several categories of low value care such as board certification, specialty, disciplin- request. use of ineffective or unproven tests or treat- ary actions), periodic training and 3. Complaints (against URAs, payers, ments on patients or use of effective tests or description of training, retraining/termi- PROs, treating providers, and resolution treatments on an inappropriately selected nation. of identified issues). patient.34 Some examples of low value care 2. Timeliness of decisions to URA. 4. Disciplinary actions. include imaging for non-specific low back 3. Determination outcomes including pain,35 opioids for chronic non-cancer approvals, partial or modified 5 INFORMATION MANAGEMENT, pain, lumbar fusion for degenerative dis- approvals, denials. ease without instability,6 meniscectomy for 4. Rates of appeals and overturns. SECURITY, AND degenerative meniscal tears.13,14 WC sys- 5. Successful peer-to-peer contact rate CONFIDENTIALITY tems are similarly affected by these system- (with identification of root causes of System protections for security and atic problems and often have inferior lack of contact). confidentiality are critical: outcomes in comparison to group health 6. Regulatory compliance. settings. Treatment guidelines and UR have 7. Results of reviewer QA audits including 1. UR agents must demonstrate and moni- been implemented in WC to address these any sub-vendors; description of audited tor mechanisms for electronic transfer of cost and quality concerns. Several orga- components and who performs quality information (requesting provider sub- nizations have made recommendations to audits; interrater reliability; interven- missions and notification, referrals to improve high value care and reduce low tions for reviewers who do not meet peer UR reviewers, and receipt of deter- value care. The American College of Physi- quality metrics. minations, maintenance of records, com- cians has a high value care initiative to 8. Complaints (including the source and munications with jurisdictions, etc). improve health, avoid harms, and eliminate focus of the complaint) and resolution 2. Jurisdictions must demonstrate and wasteful practices.36 Academy Health and of identified issues. monitor mechanisms for electronic the American Board of Internal Medicine 9. Maintenance of confidentiality includ- transfer of information (eg, fax, secure Foundation convened numerous stakehold- ing any breaches and resolution. email or text, secure portals, etc), over- ers to discuss how researchers and stake- sight and interventions with UR agents, holders can partner to reduce unnecessary Provider Networks or IRO/IMR review entities. care.37 Provider networks are health care While guidelines vary in methodol- delivery systems including contracted RESEARCH FINDINGS ogy, quality, applicability, and acceptance, physicians and other health care providers REGARDING UR there is some evidence that adherence to for the purpose of delivering necessary UR programs have been designed guidelines can improve outcomes. A retro- medical and health care services. Provider and implemented to achieve several speci- spective analysis of low back claims (14,787 networks should monitor provider qualifi- fied goals including the promotion of cost- low back episodes in 8300 employees) from cations, as well as, performance and patient effective and high-quality care and a large employer evaluated treatment pat- outcomes. Examples of relevant metrics improvement of patient safety. However, terns and congruence of care in comparison include: it is important to understand the current to a synthesis of recommendations for

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diagnosis and treatment of low back pain. Observations regarding payment for system quality, evidence-based guide- The researchers found that adherence to authorization for requested services in lines developed with community-based guideline recommendations regarding imag- WC demonstrate that the majority of care expert input to address frequent treatments ing, medications, and surgery was associated is approved, often without formal UR. In associated with high cost and poor out- with lower resource utilization and total California, there is currently a well-defined comes, and ability to conduct outcomes costs for low back care. The one area where UR system using evidence-based treatment studies (including lumbar fusion, opioids, guideline incongruence demonstrated lower guidelines, the Medical Treatment Utiliza- imaging for low back pain, etc).46 From cost was with early referral for physical tion Schedule or MTUS, and an IMR pro- 1993 through 1998, 100,005 UR reviews therapy or chiropractic care, suggesting cess to resolve medical necessity disputes. were conducted. The overall denial rate for the benefit of early referral for rehabilitation An analysis from 2014 to 2015 found that guideline-based reviews was 7.3%. The care.38 Controllable absenteeism decreased almost 85% of requests for authorization highest denial rates were for low value care significantly as the result of adoption of were paid without UR. Of the 15.3% sub- requests including thoracic outlet surgery evidence-based guidelines and other health mitted for UR, 59.8% were approved by (19.1%) and lumbar fusion (17.7%) sug- and safety measures.39 non-physician review. Physician review gesting that evidence-based guidelines Another study evaluated the impact of resulted in 29.9% approvals and 70.1% could help improve UR efficacy to identify guideline compliance involving 45,951 modification or denials. Overall, only potentially inappropriate care.9 Opioid pre- indemnity claims from four insurers. The 1.1% of requests were modified and 3.2% scribing guidelines were developed and researchers developed a compliance score were denied.44 Studies of IMR results sug- implemented in 2007 with upper limit rec- (low vs high) and assessed levels of com- gest that most UR denials and modifica- ommendations to not exceed 120 morphine plexity based upon diagnosis and treatments tions appear to be valid. Recent findings equivalent dose (MED) and dissemination provided.3 Official Disability Guidelines from the IMR process in the first part of of many prescriber tools. This resulted in Treatment in Workers’ Comp (ODG) from 2018 note that 90.1% of denials were decline in chronic opioid therapy (6.3% to Work Loss Data Institute (now owned and upheld on medical dispute review. Uphold 4.7% of incident users), 27% reduction of published by MCG Health and available rates varied by request, ranging from 77.8% MED for schedule II opioids, 35% decline electronically at www.mcg.com/odg) was for psych services to 89.6% for injections, in workers on MED more than or equal to selected as reference.24 Cases with low com- 90.8% for surgery, 90.9% for opioids, 120, and 50% fewer opioid overdose deaths pliance were associated with 13.2% increase 92.5% to 92.8% for chiropractic and physi- in WC.47,48 in claim duration and 37.9% increased med- cal therapy, and 93% for acupuncture.45 Carefully run UR with high quality ical cost. The difference in duration and cost UR processes have had to adapt evidence-based guidelines can result in cost between low and high compliance care recently to the inclusion of formulary rule- savings by reducing low value care. A sub- became more pronounced as medical com- making in some states. California imple- sequent analysis of outcomes of UR for plexity increased.3 A recent analysis involv- mented a formulary rule effective various treatment requests noted a return ing acute, work-related low back pain claims January 2018 including a list of ‘‘exempt’’ on investment for discography $6.39, inpa- from Utah (excluding major trauma, fracture medications that do not require prospective tient cases $3.52, imaging $2.29, outpatient or history of spinal fusion) assessed ACOEM review if supported by the MTUS, ‘‘non- physical medicine $1.89, outpatient cases guideline compliance using an occupational exempt’’ and ‘‘not listed’’ drugs. Initial $1.83, and spinal injections $1.51.49 Updated medicine expert rating score. The research- analysis of results observed 77.6% UR analysis of the downstream impact of UR ers found a significant trend of increasing approvals, 7.8% modifications, and 14.6% found that reduction of unsupported imaging medical and total claim cost with decreasing denials of formulary requests.11 The Texas for low back pain was associated with reduc- compliance with the ACOEM Guidelines.8 Department of Insurance Workers’ Com- tions in injections, surgeries, mean medical Other studies have similarly observed pensation Research and Evaluation costs, and disability duration.50 improved outcomes including return to work Group12 also found an impact of adopting There is some evidence from other for patients with low back pain when MRI a formulary rule and evidence-based closed jurisdictions that UR and evidence-based utilization and opioid prescribing was con- formulary using ODG24 recommendations. guidelines can result in cost savings. Cal- sistent with guideline recommendations.40– In Texas, drugs are classified as ‘‘N-drugs’’ ifornia adopted the ACOEM Practice 42 In contrast, some studies have reported (not recommended) or ‘‘Y-drugs’’ (recom- Guidelines in 2004 along with other WC mixed results. An analysis of 101,457 low mended). The number of N-drugs reforms. An analysis of early results noted back and 46,742 shoulder claims from a decreased over 80% and N-drug costs fell reductions in most interventions including large WC insurer looked at guideline con- over 70% after adoption of these changes. physical therapy, chiropractic, evaluation and cordance using recommendations from the Prescriptions and other drug costs also fell management, radiology, and injections.51 ACOEM Occupational Medicine Practice between 5% and 25%. Another analysis of Texas WC reforms have included adoption Guidelines23 (now owned and published the impact of the Texas closed formulary of ODG guidelines including a closed formu- by the Reed Group and available electroni- concluded lower pharmacy costs due to the lary, with cost savings noted above. However, cally through MDGuidelines1 at https:// reduction of non-preferred drugs, and results of medical cost control in other states www.mdguidelines.com/) and ODG,24 decreased spending on non-preferred drugs that have UR options vary.52 observed a lack of consistent findings of did not lead to increased expenditures on There is a paucity of information guideline concordance and return to work other types of care including preferred regarding the evidence of potential harm across multiple recommendations. However, drugs or spending on non-pharmacy medi- associated with UR, though some informa- excessive physical therapy, bracing, and cal care.10 tion is available regarding patient and treat- injections were generally associated with There are some observations that UR ing provider satisfaction and impressions. slower return to work. The authors suggested can improve quality and control cost. The A group health study found lower patient that unmeasured factors including injury most robust evidence comes from Wash- satisfaction in settings where there were characteristics, pain, and patient preferences ington, a state where most employers pur- preauthorization requirements for patient could account for some of these findings chase insurance from a designated public access to specialists.53 A physician survey where guideline concordance did not corre- agency. Other system advantages include conducted regarding impressions of prior late as well with outcomes.43 an office of the medical director responsible authorization on patients noted that: 92%

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perceive care delays, 92% opine a negative systems, assist the ease of requesting care, decisions. Some evidence-based guidelines impact on patient clinical outcomes, and maximize the frequency and ease of peer- have implemented tools to assist with these 78% believe that patients sometimes aban- to-peer conversations where needed, and decisions as well, including the MDGuide- don care. In addition, 84% of physicians advance the speed of obtaining UR deter- lines1 Diagnosis and Related Treatment report high or extremely high burden on mination results and processing appeals (DART) tool to access diagnostic and treat- physicians and office staff due to preautho- when requested. ment recommendations from the ACOEM rization.54 There is a need for information UR system quality similarly needs to Practice Guidelines,23 or the ODG Treat- regarding potential patient harm resulting improve. Evidence-based guidelines should ment Analyzer on Outcomes (TAO), also from delays of care, modification (partial be applicable, high quality, current, and known as the ODG UR Advisor.24 certification) or denials including clinical transparent. There are needs for better edu- Consideration of costs as a primary outcome (including functional improve- cation of treating providers and peer UR rationale for medical appropriateness of ment and return to work), satisfaction, per- reviewer training. Peer UR reviewer care is usually not permitted in most juris- ceived injustice, and litigation. Potential credentialing, oversight, quality assurance dictions, as well as URAC and NCQA adverse UR impact on treating providers using qualified physicians should be standards. This is determined by the laws could include validation of rates of care enhanced, and timely intervention assured and regulations of the jurisdiction, or poli- delays, abandonment of care, and clinical for peer UR reviewers who do not meet cies from accrediting organizations. How- outcomes. In addition, there is need to quality standards. As part of this initiative, ever, there are some situations for which the identify whether strict adherence to evi- ACOEM has developed The Eight Ethical only significant difference between treat- dence-based guideline affects patient satis- Values and Principles of Utilization Review ment options is indeed cost (eg, requesting faction with clinicians or insurers. Further (see Appendix B).55 System quality two 5 mg tablets vs one 10 mg tablet of the areas of interest include the effect of admin- improvement needs should apply to jurisdic- same medication with a large difference in istrative burdens on care delivery and finan- tional appeal systems including IMR (Cal- costs; requesting a combination pill con- cial viability of the practice of medicine. ifornia) and IRO (Texas). Jurisdictions taining two over-the-counter [OTC] medi- should consider the need to develop and cations at a significantly increased cost vs CONCLUSION implement mechanisms to receive, evaluate taking two less expensive OTC pills). Such The rationale for use of UR in WC is and address complaints regarding URAs (eg, decisions can be made at other levels from noted for several reasons. Despite the exis- complaints, quality deficiencies), peer UR the treating physician to the pharmacy ben- tence of a number of evidence-based guide- reviewers (eg, complaints, quality deficien- efits manager or insurer but permitting UR lines on a variety of subjects, practice gaps cies), treating providers (eg, complaints, to address costs when there is no significant continue as evident by overuse of low value quality of care concerns, excessive rates of clinical difference in options may be a and potentially harmful treatments.4–7,13– IMR requests with upheld decisions). useful addition to the UR process. 15,33–35 There is also evidence that guide- The nature of WC as state-based The future provides many other line concordant care is more likely to be systems has inherent challenges due to opportunities for enhancing the value of associated with improved outcomes.3,38–42 significant variability of policies and pro- UR to the injured worker and health care UR is an important and complex element cedures across jurisdictions. Adoption of system. The integration of artificial intelli- that is one means to improve outcomes and more consistent procedures and high-qual- gence, EHRs and information systems will control costs.9,10,46–51 ity evidence-based guidelines applicable to provide improved workflow and processes, However, UR systems have deficien- WC could potentially improve system per- better access to secure medical records, cies and potential harms that need to be formance, provider and patient understand- faster and more consistent decisions and addressed. Currently, UR is often seen as a ing, overall care and outcomes. automated decisions, with improved devel- transactional cost, that is, the cost of a UR Given the administrative and cost opment and application of evidenced-based review versus potential cost savings that burdens associated with UR, alternatives medical guidelines. These integrated sys- results from denial or modification (partial should be explored. Some states (Califor- tems offer the potential for improved track- certification) of care requests. Future evolu- nia, Massachusetts) have implemented reg- ing, reducing turn-around times and delays tion of UR as a component of care manage- ulations to reduce the burden of UR in treatment decisions, and ultimately more ment should include longer term and involving certain initial treatment options cost-effective and better outcomes for the comparative efficacy outcomes, including consistent with guidelines. In New York, injured worker. The EHR and information functional outcomes from treatment,2 treating providers can provide initial care systems can track outcomes and collate and improved patient safety, and longer-term for select conditions within the parameters aggregate data from multiple carriers, bill- overall treatment costs instead of short-term of the NY Medical Treatment Guidelines ing systems, pharmacy benefit managers to transactional costs. More research is needed (Neck, Back, Shoulder, Carpal Tunnel Syn- improve evidence-based medicine guide- to assess the efficacy of UR including patient drome, Knee, Non-acute Pain), but need to lines by analyzing real world outcomes outcomes, patient safety, system costs versus request approval for care outside of guides associated with specific treatment interven- potential harms including delays of care and (see New York State Workers’ Compensa- tions in real world settings. inferior patient outcomes due to unsupported tion Board. Medical Treatment Guidelines Artificial intelligence and evidence- UR denials, and the adverse impact on and Variance Requests). Some outcomes- based medicine will interact to ease the patient and provider satisfaction. based networks may exempt specific treat- burden of the UR pre-authorization process UR system efficiencies need to ing providers from some UR requirements and improve cost-effectiveness of UR deci- improve, and several recommendations based upon their demonstrated quality out- sion-making. Outcome tracking holds the should be considered. There is an overall comes. Another option for insurers to con- promise of limiting UR compliance to pro- system benefit from decreasing unneces- sider is to analyze their UR, bill review, and viders with poor outcomes, or treatment sary UR (eg, guideline consistent conser- claim costs data to determine whether some requests requiring closer scrutiny, outside vative care for acute injuries). There is a lower risk, lower cost treatment requests of guidelines or experimental. Improved need to reduce the burden on treating pro- may be better handled from an auto- information systems and EHR can improve viders and their patients, enhance provider approval standpoint. Decision support sys- the timely access and review of the appro- understanding of how to navigate UR tems are available to assist with these priate medical record elements needed for

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timely and cost-effective decision making. 7. Darlow B, Forster BB, O’Sullivan K, O’Sulli- Available at: http://www.mdguidelines.com. van P. It is time to stop causing harm with Accessed December 3, 2019. Information systems can improve access to inappropriate imaging for low back pain. Br J guidelines and formularies for all parties 24. ODG by MCG. Available at: https://www.mcg. Sports Med. 2017;51:414–415. com/odg/. Accessed May 7, 2020. with improved training programs for proper 8. Owens JD, Hegman KT, Thiese MS, et al. 25. California Division of Workers’ Compensation. use and application. The current difficulty Impacts of adherence to evidence-based medi- DWC Physician Education; 2019. Available at: in accessing, interpretation and variability cine guidelines for the management of acute low https://dir.ca.gov/dwc/CaliforniaDWCC- of the jurisdictional regulations will be back pain costs of worker’s compensation claims. ME.htm. Accessed December 3, 2019. J Occup Environ Med. 2019;61:445–452. resolved with recognition of the need for 26. American College of Occupational and Environ- 9. Wickizer TM, Franklin G, Gluck JV, Fulton- improved consistent jurisdictional pro- mental Medicine. Drug Formularies in Workers’ Kehoe D. Improving quality through identifying Compensation; 2016. Available at: https://acoe- cesses that avoid duplication, add clarity, inappropriate care: the use of guideline-based m.org/Advocacy/Guidance-and-Position-State- and ease of access for all stakeholders. This utilization review protocols in the Washington ments/Drug-Formularies-in-Workers-Compen- of course requires that all stakeholders State Workers’ Compensation System. J Occup sation. Accessed December 3, 2019. Environ Med. 2004;46:198–204. work together ethically and in partnership 27. International Association of Industrial Accident to make meaningful changes. These 10. Dillender M. The impact of a closed formulary Boards and Commissions Medical Issues Com- on prescribing patterns in the treatment of mittee. A Discussion on the Use of a Formulary changes hold the promise of improving injured workers. Econ Lett. 2016;145:88–91. in Workers’ Compensation. IAIABC; 2016. the quality and cost-effectiveness of health 11. Swedlow A, Bullis R. Initial UR and IMR Available at: https://www.iaiabc.org/images/ care decisions, outcomes, and satisfaction Prescription Drug Outcomes Under the Cali- iaiabc/Resources/Discussion-Use-Formulary- of all stakeholders. fornia Workers’ Comp Formulary. Oakland, Work-Comp-IAIABC-04-27-16.pdf. Accessed CA: California Workers’ Compensation Insti- April 1, 2019. tute; 2018. ACKNOWLEDGMENTS 28. International Association of Industrial Accident 12. Texas Department of Insurance (TDI) Workers’ Boards and Commissions (IAIABC). A Discus- This document was developed by the Compensation Research and Evaluation Group. sion on the Use of a Formulary in Workers’ ACOEM Utilization Review Task Force Impact of the Texas Pharmacy Closed Formulary. Compensation. State Snapshots. IAIABC; under the auspices of the Council on Austin, TX: Texas Department of Insurance; 2019. Available at: file:///C:/Users/julie/Down- OEM Practice. Members of the Task Force 2016 , Available at: https://www.tdi.texas.gov/ loads/Formulary_State-Snapshots_June- reports/wcreg/documents/formulary16.pdf. 2019%20(8).pdf. Accessed September 20, 2019. include Melissa Bean, DO, MBA, MPH, Accessed December 2, 2019. 29. U.S. Department of Health and Human Services. FACOEM (Co-Chair), Robert Blink, MD, 13. Roos EM, Thorlund JB. It is time to stop menis- Summary of the HIPAA Privacy Rule. Available MPH, FACOEM (Co-Chair), Rajiv Das, cectomy. Br J Sports Med. 2017;51:490–491. at: https://www.hhs.gov/sites/default/files/priva- MD, MPH, MS, Michael Erdil, MD, 14. Siemieniuk RAC, Harris IA, Agoritsas T, et al. cysummary.pdf. Accessed December 3, 2019. FACOEM, Lisa Galloway, MD, FACOEM, Arthroscopic surgery for degenerative knee 30. U.S. Department of Health and Human Ser- Lee Glass, MD, JD, Stephen Levit, MD, arthritis and meniscal tears: a clinical practice vices. HIPAA Breach Notification Rule. Avail- guideline. BMJ. 2017;357:j1982. able at: https://www.hhs.gov/hipaa/for- David McKinney, MD, MPH, FACOEM, professionals/breach-notification/index.html. Chang Na, MD, FACOEM, Lee Okurowski, 15. Jarvinen TL, Sihvonen R, Malmivaara A. Arthroscopic partial meniscectomy for degen- Accessed December 3, 2019. MD, MPH, Charles Prezzia, MD, MPH, erative meniscal tear. N Engl J Med. 31. Confidentiality of Medical Information Act FACOEM, Jill Rosenthal, MD, MPH, MA, 2014;370:1260–1261. (CMIA). Available at: https://irb.ucsd.edu/ FACOEM, Adam Seidner, MD, MPH, and 16. Chou R, Atlas SJ, Stanos SP, Rosenquist RW. CMIA.pdf. Accessed March 20, 2019. Tanisha Taylor, MD, MPH, FACOEM. The Nonsurgical interventional therapies for low 32. U.S. Equal Employment Opportunity Commis- Task Force appreciates the assistance of back pain: a review of the evidence for an Amer- sion. The Genetic Information Nondiscrimina- ican Pain Society clinical practice guideline. tion Act of 2008; 2008. Available at: https:// Ronald F. Teichman, MD, MPH, FACP, Spine (Phila Pa 1976). 2009;34:1078–1093. www.eeoc.gov/laws/statutes/gina.cfm. FACOEM who served as an Editor for 17. Freeman BJ, Fraser RD, Cain CM, Hall DJ, Accessed December 3, 2019. this document. Chapple DC. A randomized, double-blind, con- 33. Brownlee S, Chalkidou K, Doust J, et al. 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Available at: https://www.acponline.org/ Environ Med. 2016;58:519–524. Assoc J. 2010;182:E839–E842. clinical-information/high-value-care. Accessed September 20, 2019. 4. Mafi JN, McCarthy EP, Davis RB, Landon BE. 21. The AGREE Collaboration. Development and Worsening trends in the management and treat- validation of an international appraisal instru- 37. Esmail LC, Wolfson DB, Simpson LA. Reduc- ment of back pain. JAMA Intern Med. ment for assessing the quality of clinical prac- ing low value care: research questions identified 2013;173:1573–1581. tice guidelines: the AGREE project. Qual Saf by researchers, patients, physicians, and stake- Health Care. 2003;12:18–23. holders. In: AcademyHealth; 2016. Available at: 5. Ashburn MA, Fleisher LA. Increasing evidence 22. GRADE Working Group. Criteria for Applying https://www.academyhealth.org/files/AH- for the limited role of opioids to treat chronic ABIMF%20White%20Paper%20FINAL.pdf. noncancer pain. 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39. Allen H, Bunn W, Erdil M. Improving Care for APPENDIX A Genetic Information Nondiscrimi- Low Back Pain. Presented at the American nation Act of 2008 (GINA) Occupational Health Conference, May 4, : A federal law 2015, Baltimore, MD. GLOSSARY OF TERMS that protects individuals from genetic dis- 40. Volinn E, Fargo JD, Fine PG. Opioid therapy for American College of Occupational crimination in health insurance and employ- nonspecific low back pain and the outcome of and Environmental Medicine Occupa- ment. Available at: https://www.eeoc.gov/ chronic work loss. Pain. 2009;142:194–201. tional Medicine Practice Guidelines laws/statutes/gina.cfm. 41. Webster BS, Cifuentes M. Relationship of early (ACOEM Practice Guidelines): A nation- Health Insurance Portability and magnetic resonance imaging for work-related ally recognized, evidence-based treatment Accountability Act of 1996 (HIPAA): acute low back pain with disability and medical utilization outcomes. J Occup Environ Med. guideline. ACOEM Practice Guidelines are Legislation that established national stand- 2010;52:900–907. the regulatory guidelines in several juris- ards for the protection of personal health 42. Webster BS, Verma SK, Gatchel RJ. Relationship dictions. ACOEM Practice Guidelines information including standards for data between early opioid prescribing for acute occu- define best practices for key areas of occu- privacy (https://searchcio.techtarget.com/ pational low back pain and disability duration, pational medical care and disability man- definition/data-privacy-information-privacy) medical costs, subsequent surgery and late opioid use. Spine (Phila Pa 1976). 2007;32:2127–2132. agement. They are intended to improve the and security provisions for safeguarding efficiency and accuracy of the diagnostic 43. Roberts ET, DuGoff EH, Heins SE, et al. Evalu- medical information. Available at: https:// ating clinical practice guidelines based on their process as well as identify the effectiveness www.hhs.gov/sites/default/files/privacysum- association with return to work in administrative and risks of individual treatments in resolv- mary.pdf. claims data. Health Serv Res. 2016;51:953–980. ing an illness or injury—helping workers Independent Medical Review 44. David R, Ramirez B, Swedlow A. Medical return to normal activities as quickly (IMR): A review performed by an indepen- Review and Dispute Resolution in the Califor- and safely as possible (http://acoem.org/ dent entity to provide an objective, unbi- nia Workers’ Compensation System. Oakland, CA: California Workers’ Compensation Insti- Practice-Resources/Practice-Guidelines- ased determination regarding medical tute; 2015. Center). ACOEM Practice Guidelines are necessity for requested care that has been Independent Medical Review available electronically through MDGuide- denied after peer UR performed for the 45. Bullis R, David R. 1 Decisions January 2014 through June 2018. lines published by Reed Group. Available insurer, TPA, URA, etc. In some states Oakland, CA: California Workers’ Compensa- at: https://www.mdguidelines.com/. and jurisdictional WC systems, there may tion Institute; 2018. Appeal UR review: See Utilization be a specified IMR appeal option and pro- 46. Ruel N. Introduction to evidence-based decision making in a public workers’ compensation review Appeal UR and Reconsideration UR cess that is mandated by law, as in Cali- agency. Phys Med Rehabil Clin N Am. review. fornia, after a request for care is denied by 2015;26:435–443. Concurrent UR review: See Utili- the payor. 47. Franklin GM, Mai J, Turner J, Sullivan M, zation review. Independent Review Organization Wickizer T, Fulton-Kehoe D. Bending the pre- Confidentiality Medical Informa- (IRO): An organization that performs inde- scription opioid dosing and mortality curves: tion Act (CMIA): The Confidentiality of impact of the Washington State opioid dosing pendent external peer UR review for an guideline. Am J Ind Med. 2012;55:325–331. Medical Information Act (CMIA) is a insurer, TPA, URA, etc, using qualified 48. Garg RK, Fulton-Kehoe D, Turner JA, et al. California state law that adds to the federal physicians and other appropriate health Changes in opioid prescribing for Washington protection of personal medical information care providers. In some states and jurisdic- workers’ compensation claimants after imple- and records under the Health Information tional WC systems, there may be a speci- mentation of an opioid dosing guideline for Portability and Accountability Act (HIPAA). fied IRO appeal option and process that is chronic noncancer pain: 2004 to 2010. J Pain. 2013;14:1620–1628. Available at: https://irb.ucsd.edu/CMIA.pdf. mandated by law, as in Texas, after a 49. Stockbridge H, d’Urso N. Application and out- Continuous Quality Improvement request for care is denied by the payor. comes of treatment guidelines in a utilization (CQI): The systematic process of identify- Medical Treatment Utilization review program. Phys Med Rehabil Clin N Am. ing, describing, and analyzing strengths and Schedule (MTUS): A set of regulations 2015;26:445–452. problems and then testing, implementing, found in title 8, California Code of Regu- 50. Graves JM, Fulton-Kehoe D, Jarvik JG, Frank- learning from, and revising solutions (defi- lations section 9792.20 through 9792.27.23 lin GM. Impact of an advanced imaging utilization review program on downstream health nition from the US Department of Health that contain medical treatment guidelines care utilization and costs for low back pain. Med and Human Services). and rules for determining what is reasonable Care. 2018;56:520–528. Evidence-based medicine (EBM): and necessary medical care. The MTUS is 51. Swedlow A, Ireland J. Analysis of California The explicit and judicious use of currently based on the principles of evidence-based Workers’ Compensation Reforms. Oakland, available, highest quality medical evidence medicine. That means treatment decisions CA: California Workers’ Compensaiton Insti- tute; 2007. from research studies and literature reviews, are guided by recommendations supported 52. Tanabe R, Rothkin K. WCRI 2018 Workers’ to guide clinical decision making about the by the best-available evidence. See: https:// Compensation Medical Cost Containment: A medical care of individual patients. This is www.dir.ca.gov/dwc/MTUS/MTUS.html National Inventory, 2018. Cambridge, MA: the basis for credible clinical guidelines and National Committee for Quality Workers’ Compensation Research Institute; 2018 peer UR review decisions. Assurance (NCQA): A national, indepen- 53. Kerr EA, Hays RD, Mitchinson A, Lee M, Siu Expedited UR review: See Utiliza- AL. The influence of gatekeeping and utiliza- dent, non-profit organization that evaluates tion review on patient satisfaction. J Gen Intern tion review. and accredits health care plans based on Med. 1999;14:287–296. Formulary (Drug formulary): quality measurements, in addition to being 54. American Medical Association. 2017 AMA Lists of prescription drugs, generic or brand involved in other activities to assess and Prior Authorization Physician Survey. Chicago, names, developed by health plans, phar- improve quality and care outcomes and pro- IL; 2018. Available at: https://www.ama-ass- n.org/sites/ama-assn.org/files/corp/media- macy benefits management companies or tect consumers. See: https://www.ncqa.org/. browser/public/arc/prior-auth-2017.pdf. states to identify and/or direct prescribing Official Disability Guidelines Accessed September 20, 2019. of value added and cost-effective drug (ODG) Treatment in Workers’ Compen- 55. American College of Occupational and Envi- choices. State defined WC formulary drug sation (ODG by MCG): A nationally ronmental Medicine. The Eight Ethical Values lists are commonly developed in conjunc- recognized, evidence-based treatment and Principles of Utilization Review; 2019. Available at: https://acoem.org/acoem/media/ tion with formulary rules or regulations and guideline. ODG is the regulatory guideline News-Library/UR-1-page-Flyer-6-14-2019.pdf. are consistent with statutory evidence- in several jurisdictions. ODG by MCG ‘‘pro- Accessed April 3, 2020. based treatment guidelines. vides independent, evidence-based medical

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treatment guidelines and return-to-work appropriateness of requested treatment or and performs UR for an insurer, employer, guidelines for conditions commonly associ- services following regulatory guidelines. TPA. URAs may be required to be certified ated with the workplace.’’ ODG is electroni- UR decisions are based upon medical neces- and registered to conduct UR in specific cally available and published by ODG/MCG sity, not cost or compensability. jurisdictions. Health. Available at: https://www.mcg.com/ Types of UR Reviews: UR can be Utilization Review Accreditation odg/. performed at different times during the Commission (URAC)/American Accred- Outcomes Based Network (OBN): course of treatment. itation Commission: A national, indepen- A network of providers who provide con- dent, non-profit organization that evaluates sistent high-quality care focused on out- Prospective UR review. UR review and accredits health care plans based on comes versus traditional discount and before treatment starts. Sometimes quality measurements, in addition to being access-based networks. called precertification or preauthoriza- involved in other activities to assess and Peer Review: A review performed tion. improve quality and care outcomes and by a qualified health care provider for UR Concurrent UR review. UR review per- protect consumers. See: https://www.ura- or non-UR decisions. Peer review is also formed regarding continuation of care a c.org/ performed outside of the regulatory UR patient is already receiving. system to comment on appropriateness of Retrospective UR review. UR review APPENDIX B requested services, but may also consider performed after care has been delivered causation, cost, alternative treatment Appeal UR review. A third level peer UR The Eight Ethical Values and options, or other considerations. review following a denial of the request Principles of Utilization Review Peer UR Review: See utilization at the initial peer UR review second level This document was approved by the review. and/or reconsideration. Usually per- ACOEM Board of Directors on April 27, Peer Reviewer (UR Reviewer): The formed by a board-certified provider in 2019. appropriate health care practitioner (clini- active practice in the same or similar Occupational and environmental cal peer) who reviews a case (second or specialty as the treating doctor. health professionals have an obligation to: third level UR review) to offer recommen- Reconsideration UR review: In some 1. Promote Clinically Correct, dations regarding medical necessity or jurisdictions, a reconsideration UR Patient-Centric Decisions appropriateness of requested services. review can be performed when care Acknowledge that effective and Reviewer qualifications are determined has been denied per second level UR medically necessary care decisions that by the nature of the request and jurisdic- review in the absence of a successful place patient welfare and clinical outcomes tional requirements. peer to peer conversation. In other states, in the forefront are a key priority. Peer Review Organizations (PROs): like Texas, a reconsideration is an appeal 2. Support Evidenced-Based Med- Independent entities that perform Peer UR UR review. ical Guidelines and Formularies review or Peer review for insurers, TPAs, Expedited UR review, Urgent care UR Recognize that high-quality, evi- URAs using qualified physicians and other review. UR review requested by a treat- dence-based guidelines and formularies appropriate health care providers. ing provider for urgent care (per the can help assure that patients receive appro- Prospective UR Review: See Utili- treating provider). Examples include priate care while avoiding ineffective and/ zation review. care or treatment requests where there or potentially harmful care. Quality Assurance (QA): Monitor- may be jeopardy to the life or health of 3. Require Qualified Peer ing and evaluation of the quality and integ- the patient, risk of significant pain or Reviewers and Administrative Oversight rity of program processes and decisions failure to regain maximal function in the Ensure that utilization review (UR) rendered regarding care requests. absence of the requested care or treat- peer reviewers for all denials, modified Reconsideration UR Review:In ment. Expedited or Urgent care UR decisions, and appeal reviews have ade- some jurisdictions, a reconsideration UR reviews are completed within 72 hours. quate education, training, specialty board review can be performed when care has Types of UR Reviewers: UR can be certification, scope of practice, licensure, been denied per second level UR review performed by the following types of and experience and meet any regulatory in the absence of a successful peer to peer reviewers: requirements. Avoid conflicts of interest conversation. In other states, like Texas, a and behave honestly and ethically when reconsideration is an appeal UR review. First level UR review. UR review per- requesting authorization or rendering UR Requesting (Treating or Ordering) formed by appropriate licensed or certi- peer-review decisions. Provider: The physician or other health fied health professionals to determine if 4. Strive for Timely Reviews and care provider who specifically prescribes care requests meet clinical review crite- Reduction of Administrative Burdens the health care service being reviewed. ria to merit certification. First level Develop and implement policies and Retrospective UR review: See uti- review can approve but cannot deny or procedures to facilitate timely submission lization review. modify care. of requests for communicating authoriza- Third-party Administrator (TPA): Second level UR review. UR review tion among all parties and rendering of UR An organization that performs a number of performed by a clinical peer for requests peer-review decisions. Avoid unnecessary services for the insurer or employer who that do not meet First level clinical UR delays of care for patients and administra- underwrites the risk. Administrative ser- review criteria. tive burdens for practices. vices may include claims processing, cus- Third level UR review or Appeal UR 5. Enhance Professional Interac- tomer service, management of provider review. UR review performed after treat- tion Between the Provider and Peer networks, UR, etc. ment has been denied by Second level Reviewer Turnaround Time (TAT): Time- UR review. See also Appeal UR review Strive for peer-to-peer conversation frame in which UR decision must be com- and Reconsideration UR review. when additional information is necessary. pleted and documentation submitted. Utilization Review Agent (URA) Conversations must be collegial and pro- Utilization Review (UR):Deter- or Utilization Review Organization fessional with a focus on determining if mination of medical necessity or (URO): An organization that administers care is consistent with guidelines while

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recognizing circumstances with exceptions 7. Maintain Secure, Confidential UR system with engagement of all to guidelines and emphasizing treatment Information Systems stakeholders and active medical dir- based upon functional outcomes. Protect confidential patient medical ector (MD or DO) oversight. Quality 6. Improve Basic Understanding of information throughout the entire UR sys- improvement requires assessment of the UR Process When Performing Peer tem. Adhere to all applicable laws, regula- relevant outcomes metrics, comparison Review tory requirements, and ethical standards to evidence-based medicine and best Communicate and collaborate effec- relevant to communications, transmission, practice, quality assurance reviews, tively with health care providers when per- handling, or storage of medical records or root cause analysis for quality defi- forming UR peer review to improve protected health information. ciencies, functional assessment, and provider knowledge of the UR system 8. Implement Total Quality implementation of strategies to im- and regulatory requirements, as well as Improvement prove outcomes with monitoring of evidence-based medicine and guidelines Commit to ongoing total quality efficacy of interventions to correct or review criteria. improvement throughout the entire deficiencies.

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