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Many physicians are at odds with workers compensation claims management professionals over how to best navigate a long-standing but evolving process used to get injured workers well and back to work: utilization reviews.
Disagreements over the effectiveness of elements of the utilization review process, which insurers say ensures they only cover medically necessary drugs and treatments, can slow down treatment and keep workers off the job for longer, experts say.
Utilization reviews, which have been around for decades, are more frequently being mandated, and several states have introduced drug formularies and treatment schedules. The process requires a back and forth between doctors and claims handlers, involving documentation and imaging in some cases, to monitor care such as drugs, tests, surgery and physical therapy.
Workers comp insurers, third-party administrators and pharmacy benefits managers have grappled with the introduction of new utilization review processes for the past several years. For instance, California implemented its medical treatment utilization schedule in 2018, and New York this year introduced a program to electronically streamline utilization reviews among providers and claims handlers.
In addition, according to reports compiled by the National Council on Compensation Insurance, 15 states have in place closed-drug formularies that require prior authorizations. Many formularies and prior authorization processes were put in place due to the opioid crisis, rising medical costs and poor outcomes among injured workers, among other reasons.
Doctors, though, have long decried such prior authorization measures.
According to a survey of 1,001 doctors conducted in December 2022 by the American Medical Association, 80% said advance treatment approvals have led to early treatment abandonment, 31% said that prior authorization criteria — many of which are in place due to state regulations or parameters set by individual insurers — are “rarely or never evidence-based,” and 64% said authorization requests have led to “ineffective” initial treatments.
“It’s very frustrating because when you’re an (occupational injury) doc and you know that you’re following the science, all this does is provide a delay for getting the person better,” said Dr. Douglas Martin, medical director of the Center for Neurosciences, Orthopaedics & Spine Occupational Medicine in Sioux City, Iowa, who sees about 55 workers comp patients a week.
Dr. Martin serves as a medical examiner for several entities, including the Nebraska Worker’s Compensation Court and is president of the American College of Occupational & Environmental Medicine, whose guidelines were used to help craft the California drug and treatment formulary. He said there’s much frustration among physicians when it comes to getting approvals for sound and timely evidence-based care.
Many delays occur when it comes to physical therapy requests and can cause injuries to worsen or have significantly delayed recovery, he said.
Industry experts say they understand the problems that can arise but assert that utilization reviews go a long way in ensuring adequate care and return to work.
“We see evidence-based medicine as a tool to make sure that the employees are getting the right care at the right time, with the overall goal of getting the employee back to work to the pre-injury status,” said Leah Sharp, Franklin, Tennessee-based senior vice president with GBCARE, a unit of Gallagher Bassett Services Inc. “We don’t see it as necessarily a drag on the system; it’s care that is managed. We’re making sure that the employees are getting the right care.”
Ben Roberts, Duluth, Georgia-based vice president of utilization reviews for Genex Services, an Enlyte LLC company, said access to information on patients is often the first issue to resolve.
“Among the biggest challenges with slowing down the utilization review process are really around the completeness of the information that’s provided,” he said.
Clinical utilization review teams evaluate the medical necessity and reasonableness of treatments against evidence-based guidelines and the guidelines often have very specific requirements about what needs to be present for an approval, Mr. Roberts said.
“Delays come into play when insufficient information is provided,” he said.
Experts say educating physicians on the process is part of the solution.
Changes in documentation processes in states like California and New York can be a challenge for physicians, Ms. Sharp said.
“It’s a scenario where it’s a culture shift,” Ms. Sharp said. “If doctors take the time to learn the guidelines or understand how to put them into practice, they will see a lot less frustration than they currently do.”
Technology is also part of the answer, said Silvia Sacalis, a Tampa, Florida-based licensed pharmacist and vice president of clinical services for Healthesystems LLC.
“Some of the delays are due to challenges with workflow design and the manual turnaround of information,” she said.
More automation could streamline the process of transmitting information that is relevant and needed for utilization reviews, Ms. Sacalis said.
A scathing report on one of the country’s largest workers compensation programs highlighted the importance of utilization reviews, according to experts.