Late Friday afternoon, I received an email from the website, WorkersCompensation.com. The Workers Comp Blogwire section of their Daily Report, contained an article from the ReduceYourWorkersComp.com blog entitled, “What Is Utilization Review in Workers Compensation?”
Since it had come to my attention before the weekend began, I decided to wait a few days and write this piece now, so that it would arrive fresh on your screens Monday morning.
ReduceYourWorkersComp.com is published by Amaxx Risk Solutions, Inc., and the article was written by one of my LinkedIn connections, Rebecca Shafer, the President of Amaxx Risk Solutions, Inc. The editor of the blog is Michael Stack, the Director of Operations for Amaxx.
Upon seeing the article, I thought it would be a good idea to write something about utilization review for those in the medical tourism industry who are unfamiliar with what utilization review is, and what it does in workers’ compensation.
I have done something like this before on this blog when I discussed workers’ compensation-specific topics such as employee/employer choice, physical therapy and rehabilitation, prescription opioid drug abuse, early intervention, adjuster selection, describing what a Professional Employment Organization is, and gave you a primer on workers’ compensation terms and concepts.
It is my intention and hope that this article will interest some in the medical tourism industry to explore the implementation of medical tourism into workers’ compensation, by explaining a very vital part of the process workers’ compensation goes through to provide proper medical care to injured workers.
What is Utilization Review?
In workers’ compensation, utilization review is the process by which an outside medical expert reviews the diagnosis and treatment to determine if the proposed or completed treatment is medically necessary. There are three types of utilization review:
- Pre-certification review: occurs before medical procedure or treatment is provided
- Concurrent review: occurs during time the medical treatment or service is performed (as in a hospital stay)
- Retrospective review: occurs after a service has been provided
Utilization reviews will be completed by highly experienced nurses who will review medical records and determine if a procedure is medically necessary for the injured workers. They will also verify that there is a causal relationship between the procedure and the injury.
The company that provides the utilization review must be certified by the Utilization Review Accreditation Commission (URAC), which is the organization that establishes the standards throughout the medical field in the US for utilization review. URAC is an independent, nonprofit organization that is well-known as a leader in promoting health care quality through its accreditation, education and measurement programs. Insurers and self-insured employers would be derelict if they considered using a utilization review company that did not have certification.
Utilization Review determines medical necessity
Some months ago, I connected with someone from URAC, who gave me considerable information on the standards and how URAC determines these standards, as well as information about the accreditation process. At the time, I was thinking about writing about URAC in order to show the medical tourism industry that they needed to create such an organization as URAC, but only on a global basis. URAC’s main focus is on the domestic health care system, which includes workers’ compensation.
The task of creating such an agency would have to require not only the medical tourism industry’s input and involvement, but that of every single government health ministry, as well as other international organizations in the health care and medical tourism sphere, and all other interested stakeholders. This is further complicated by the fact, as one expert in health care and medical tourism stated in social media recently, that:
“There are no officially recognized leaders in the world with designated official authority to proclaim such terms [medical tourism, medical travel, health travel, etc.] or deem them for “official use”. Not the WHO, not the WTO, not MTQua, not the IMTCC, not the Medical Travel Commission, not the GHTC, not the ITIJ, not ISPA, ESPA, TEMOS, None of the recognized accrediting bodies of ISQua, and certainly not the MTA.”[Emphasis added]
The reason for creating such an agency is apparent when we understand that the process of utilization review as practiced here in the US is the result of the various states getting involved in determining what is or is not acceptable for review. In the US, the review company must be willing to verify that it will comply with each state’s requirements. Failure to comply results in the medical provider contesting the review, and lack of compliance with the requirements of a particular jurisdiction, results in the review being thrown out.
On a global scale, this would mean that any agency charged with the responsibility of certification of utilization review companies and setting standards would have to verify that these companies are complying with individual national requirements, which presents an even greater challenge, but if we confine our focus on the US, for the purpose of implementing medical tourism into workers’ compensation, that task will be simpler by just following the requirements of all fifty states, which are already in place and do not need to be established.
Even though states have jurisdictional guidelines, utilization reviews are not often clear cut. An experienced nurse must review all the criteria for a service request and to verify that the criteria for the medical service were met. They will also review the guidelines to see if the medical information supports the treatment. If there is no guideline on a particular treatment, the nurse will review the standard guidelines. All review decisions are based on the medical documents provided by the medical provider
If the nurse does not agree that a service is needed, it will be escalated to a physician for review. This peer review is conducted by a medical provider in the same specialty as the individual treating the injured worker.
Lastly, the peer physician will set up a peer-to-peer discussion to determine if there is a rational reason for the procedure. This will only take place once the review physician follows both the jurisdictional and standard treatment guidelines to see if they agree with or disagrees with the service under review. If the physician disagrees with the procedure, they will deny the request and submit an explanation why it is denied.
Such a peer-to-peer discussion between a review physician located in a medical tourism destination and the treating physician in the US, is much more feasible, now that communication via email, Skype and other technologies are making the transfer of medical records and information faster and more reliable. And as many medical providers in medical tourism facilities have been educated and trained in the US and other Western nations, the medical knowledge of the overseas provider and their ability to speak English is not a problem.
As readers of this blog have already learned in my previous posts, “The Faith of My Conviction: Integrating Medical Tourism into Workers’ Compensation is Possible and is not a Pipe Dream” and “Clearing the Air: My Defense of Implementing Medical Tourism into Workers’ Compensation”, I am very passionate about changing the way medical care is provided for in the American workers’ compensation system, and that I believe that opening it up to the best the world has to offer, is not only possible, it is inevitable.
It is always my hope that my posts will spark an interest in doing so from either the medical tourism industry or the workers’ compensation industry, or both. That is why I have posted them to LinkedIn groups that cover both industries, and why I continue to write.
Making excuses and ignoring the reality that is happening in other areas of business is not only foolish, it is illogical because there is so much more profit to be made in diversifying one’s reach into markets that up to now have not been tapped. Also, the diversity of the American workforce represents the best opportunity to implement medical tourism into workers’ compensation as I pointed out in my last post, “Labor Day, Immigrants and Medical Tourism: An Essay”.
By discussing what utilization review is and how the medical tourism industry can adapt it to their business model, will go a long way in bringing about the globalization and standardization of health care and medical treatment, and will provide all human beings with the same quality care that many millions already receive.
The reality of poor care around the world today is evidenced by the horrific Saran gas attack that occurred in Syria, and the recently released videos of the dead, the dying and the survivors of that attack, some of them children, that emphasizes that we have a long way to go in providing such quality care to everyone on the planet. It was even pointed out that the Syrians did not have facilities for women, so that most of the dead bodies were that of women.
Utilization review will be one way in which quality care can be assessed as necessary when the life of an individual is not threatened as it was in the videos from Syria, and those individuals who elect to have surgery abroad will know that they are receiving the proper and correct treatment from physicians who are being monitored by an independent agency responsible for overseeing the necessity of treatment.
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