August 31, 2011
Utilization Review A Tool for Controlling Costs, or a Cost Driver Itself?
by Judy Adlam
#1 — Delay In Treatment
Utilization Review is not instantaneous. Guidelines allow claims payers five days to turn around the Utilization Reviews. While five days is certainly reasonable in terms of the need for referral, review and approval/modification/denial, it is quite a long time when viewed through the lens of the waiting injured worker and the physician. It can mean five days of extra pain, and five days of added uncertainty.
#2 — Rising Costs
The cost of Utilization Review is not insignificant. Most range from $100 – $300 or more. Considering that this can be more than the cost of some therapies, it becomes evident that unnecessary UR reviews serve to drive up costs, rather than contain them.
#3 — The Wedge
This is likely the most serious of the consequences. Most of us have at some time experienced the frustration of being told by our physician that we need a procedure or a test, but that it has to first be approved by “the Insurance Company.” Although we may have become used to this, it certainly causes us to leave the doctor’s office uncertain about what the next steps will be.
In the case of Work Comp and Utilization Review, the regulations allows for up to five days for the UR process to be completed. Therefore, the Physician must wait before scheduling the procedure, diagnostic test or therapy session. And the irony is that in many cases, “the Insurance Company” selected the Physician or developed the network, and then is “second guessing” the network Physician, driving a wedge between the Physician and patient when we should be supporting the very relationship that is fundamental to returning the Injured Worker to pre-injury condition.
If I were an Injured Worker who visited a Network Provider at the direction of my Employer, and then was told by that provider that I’d have to wait for “the insurance Company” to approve the test, I might wonder why I should trust a Physician that “the Insurance Company” doesn’t even trust!