Category Archives: Utilization Review

Say Goodbye to Comp

Fellow blogger, Joe Paduda, today wrote a very prescient article about the impact the jobless economy will have on workers’ comp in the coming decades.

While the idea of driverless trucks may be something in the works, there are many factors working against it from becoming reality in the near term, and perhaps for many years to come. Laws and insurance requirements and what to do if the truck breaks down on a stretch of highway not easily accessible by repair trucks or miles from the nearest truck stop, will have to considered before driverless trucks put drivers out of work.

Yet, as Joe points out, manufacturing is already seeing a loss of jobs due to automation and higher productivity, which will lead to lower consumer costs, but will exact an even higher cost on the nation’s stability and will force politicians to come to grips with what to do with a permanently unemployed population, especially those in the service sector, who are being replaced, and will be replaced by automated cashiers, as well as those occupations tied to the workers’ comp industry.

If, as I reported yesterday, that 50% of all jobs will be gone by 2025, what do you do with those individuals who lose their jobs to machines and software?

It is a question that few have asked, and one that fewer have provided answers for. Also, what happens, as I also asked yesterday, if the 50% goes to 75% or higher?

The UBI is one idea floating around, but short of that, what else can we do to put permanently unemployed back into the workforce once technology makes them, in the words of that “Twilight Zone” episode, “Obsolete!”

It makes no sense, Joe states, to reform a system that won’t be around much longer. So, say goodbye to workers’ comp, say goodbye to claims adjusters, occupational therapists and physicians and nurses in same, pharmacy benefit managers, rehabilitation personnel, return to work specialists, case managers, utilization reviewers and bill reviewers, as well as underwriters and lawyers.

Medical Management Internship Paper, Summer 2011

No doubt, many of my readers have wondered what I learned in my MHA degree program, and why my writing has been of interest to so many of you.

Upon checking my stats for the blog, I noticed that someone had viewed a paper I wrote in the summer of 2011 for my Summer Internship course, as part of my MHA degree program requirements. The school I attended required all students without a health care background to take a one-credit course as an Intern in a health care organization.

The organization I choose was one my school already contracted with, Broadspire. At the end of the course, we were expected to write a paper about our internship for a grade in the course.

The following link will direct the reader to a copy of my paper that I hope the reader will find interesting, and will highlight my skills as a researcher and writer. Speaking engagements as well as research opportunities are most welcome, as are full-time positions and consulting opportunities.

As the summer session was very short, only three projects were undertaken, and the last one was truncated due to time constraints and the report presented to Broadspire concentrated on only two states, Florida and California.

Let me know your thoughts.

Independent Medical Review Upheld as Constitutional

As I mentioned this morning to a good friend, I normally shy away from writing about California work comp issues, but the following article by Stephanie Goldberg, is indicative of how the legal system has been corrupted to the extent that benefits are denied to injured workers when it is proved they are necessary to deal with their injuries, especially those that leave the worker unable to be gainfully employed.

In other words, the courts have helped the employers screw the workers once again, and this is not coming from ProPublica/NPR.

Here is the article from Business Insurance:|68|309|70|74|92|329|304

We can and should do better, and not just for blue collar workers, but for white collar workers as well. which is what Ms. Stevens is. And I know two other white collar women in CA who have also gotten the shaft from the system. I wrote about them in three separate articles, “The Stench of Fraud: Why Workers’ Comp Can No Longer Be a Closed System“, “The Stench of Fraud, Continued“, and “What Price Profit?“.

From what I have heard about the IMR process, not all of the reviewers are equipped or knowledgeable to review cases, and they only look at medical records (which by one account had been changed), so the process is unfair, no matter what the court said.

Workers’ comp is being undermined from within and without. It is only a matter of time until it it is completely gutted and done away with. That is the fault of stupid and greedy people, but it is also our fault for choosing leaders who allow this to happen because instead of looking out for the people, they look out for the interests of the wealthy and powerful.

Utilization Review for Workers’ Compensation: What Medical Tourism Needs to Know



Late Friday afternoon, I received an email from the website, The Workers Comp Blogwire section of their Daily Report, contained an article from the 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. 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.

Peer-to-Peer Discussion

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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