It's COMPlicated – Utility of Utilization Review

The use of utilization review in workers’ comp has staunch defenders and harsh critics.  

The defenders (insurance companies and third-party administrators, et al.) consider utilization review a basic tool to prevent unnecessary medical services and reduce costs. The critics (physicians and plaintiff attorneys, et al.) counter that it causes unnecessary delays in medical care that can result in poorer outcomes and frustration for physicians and injured workers.  

Finding the right balance in the use of utilization review is important if the system is to provide medical care that furthers the goal of effective recovery of the injured worker at a reasonable cost, which best serves the injured worker, employer, and society. This article offers three potential approaches to advance that goal. 

Many states authorize utilization review and usually describe it as a review process to ensure that medical services are medically necessary. It’s hard to argue with the appropriateness of that. For example, no one wants an injured worker to become addicted because a medical provider prescribed opioids for an excessively long period when the patient has chronic pain, especially if the drugs don’t result in significant improvement. Nor would anyone want a patient with back problems to have a spinal fusion with its less than impressive success rate if better options were available.  

The devil is in the details. 

Critics of utilization review question a process that can deny treatment considered medically necessary by the authorized medical provider or delay approval until time-consuming appeals have occurred. Specifically, they complain about the perceived biases of reviewers who refuse treatments for cost-containment considerations alone. They also note the failure to make good-faith attempts to communicate with authorized treating physicians before denying treatment. They point to excessive referrals by insurance companies and third-party administrators of requests for utilization review, as well as the practice of suddenly withholding the approval of pain medications after a long history of approving them, without a safe weaning period. Further, they cite denials based on an inconsequential variation from treatment guidelines, or without adequate explanations. 

In response, defenders point to the failure of physicians to adequately document the medical necessity of requested treatments. They also complain about incomplete medical files given to utilization reviewers, as well as the failure of some physicians to respond to opportunities for peer discussion with utilization reviewers. 

So, how do workers’ compensation systems gain the advantages of utilization review with less friction and fewer negative consequences?  

One approach is to improve communication between the physician and the utilization reviewer. Physicians should include specific references to the applicable, evidence-based medical treatment guidelines in requests for authorization of medical services, along with explanations of how the guidelines apply to the treatment requested. They should likewise offer reasonable access for peer contact with the medical reviewer, so the physician can clarify the information sent and discuss in real time the rationale for the requested treatment and the validity of the proposed treatment for the patient’s best recovery. 

A second approach is for states that allow employers to provide a panel of physicians from which injured workers must choose their authorized treating physician. In these states, employers (or their insurance companies or third-party administrators) could choose physician panels based on the doctors’ demonstrated excellence and willingness to document requests for treatment approvals on evidenced-based medicine. Then employers or their representatives could consider exempting physicians’ treatment requests from utilization review, or only requiring it when requests are made for “red flag” type treatments. Not only might this approach eliminate inappropriate delays in treatment, but also it increases the attractiveness of providing medical care to workers’ compensation patients. 

A third approach is regulatory oversight. Regulators in states that authorize utilization review can monitor the services provided in their state periodically. Reviews could include a review of a random sample of requests for authorization received by the utilization review organization in the most recent twelve-month period, using objective standards that apply to every organization reviewed. They should also consider the numbers of reviews completed; requests for treatment approved without appeal; the number denied; the number approved after appeal to the utilization review provider; and the number approved after appeal to the state regulatory agency. They should additionally be mindful of any complaints filed against the vendor and penalties assessed by the regulatory agency.  

The bottom line? Solutions are available that improve communications and provide for transparency and efficiency in the process. The hope is to retain the advantages of utilization review and minimize the friction that has been detrimental to the goal of good outcomes from medical care.  

A good starting place for solutions is that they follow the admonition in Hippocrates’ text Epidemics, “to do no harm.”