Streamlining UR: A 60-Second Seminar in Workers’ Compensation Claims Handling

Have you ever asked yourself, “Can medical treatment be streamlined by allowing the claims examiner to authorize medical services instead of involving Utilization Review (UR)”?  Under current law examiners may authorize requested medical services but are not allowed to deny or modify treatment requests based on medical grounds.  The examiner may only deny or delay requested services for legal reasons, such as when a claim is denied in its entirety. To authorize services an examiner need only fill out the bottom portion of the RFA form and fax it back to the medical provider. Physicians are often caught by surprise when an examiner authorizes services because they had anticipated a wait of several days for a response from UR as opposed to only a few hours from an examiner. Very proactive examiners may also grant permission to their field or telephonic nurses to act in their behalf to authorize services on the spot. This is especially true when coordinating a patient’s discharge from a hospital by authorizing and providing numerous items to allow for immediate discharge, such as Rx medication, transportation home, supplying durable medical equipment, and home health or nursing care services. All these requests can easily take more than a week to accomplish through regular UR channels, while a nurse can authorize everything on the spot to allow a patient to be discharged from a hospital within hours, resulting in substantial savings to the employer.

Unfortunately, very few adjusters are given authority to approve treatment requests. First and foremost, it is UR’s job to review RFAs not that of an examiner. Another reason behind not granting RFA authority to examiners is to avoid future disputes with employers and reinsurers. For example, an employer may get upset if an examiner authorizes a particular medical procedure instead of UR addressing the issue. In addition, reinsurance or excess insurance may deny reimbursement for medical services authorized by the examiner as the request was not addressed by a licensed UR professional. Therefore, to avoid future disputes many companies instruct examiners to forward all RFA’s to UR for response.

We can certainly understand why a vast majority of RFA’s should be addressed by UR; however, there are certain situations where common sense tells us it would be a waste of time and money to submit an RFA to UR, especially when the request will obviously be approved.  Why delay medical care for a week or more when approval is a certainty?  For example, when someone breaks a bone and will require surgery, why must everyone wait one week for UR to authorize a referral to an orthopedic surgeon?  Also, why must the employer pay a UR processing fee when the adjuster can authorize the referral in an instant?

Experienced examiners should be given authority to issue RFA approval in obvious situations. The goal is to provide efficient and speedy medical care.  Allowing experienced examiners and nurses permission to authorize certain RFA requests results in reduced overall claims costs, creates good will and more quickly returns an injured worker to a productive life.