Transcript Utilization Review

WCLA MCLE 11-2-11
• Utilization Review: The New Provisions &
Practical Pointers
• Wednesday November 2, 2011
• 12:00 noon to 1:00 pm
• James R. Thompson Center Auditorium,
Chicago, IL
• 1.0 Hour General MCLE Credit
Utilization Review
Applicability & Medical Treatment Guidelines
•
•
•
•
•
•
•
•
Added to Section 8.7, the Utilization Review section
Applicability: “The changes to this Section made by this amendatory Act of the
97th General Assembly apply only to health care services provided or proposed to
be provided on or after September 1, 2011.”
Do already litigated prospective medical cases involve services to be provided?
Section 8.7(a) amended in the following way:
“The evaluation must be accomplished by means of a system that identifies the
utilization of health care services based on standards of care of or nationally
recognized peer review guidelines as well as nationally recognized treatment
guidelines and evidence-based medicine evidence based upon standards as
provided in this Act.”
No change from current law? (correction of typo really)
Nationally recognized treatment guidelines and evidence based medicine: Medical
treatment guidelines: substantive as to what kind of treatment; eg. ACOEM , ODG,
AAOS
Utilization Review Standards: procedural as to how to do UR; eg. URAC
Utilization Review
Medical Treatment Guidelines
• IL does NOT ADOPT by law or by rule ANY ONE PARTICULAR
set of medical treatment guidelines; no one set is correct,
presumptively or otherwise
• There are MANY sets of medical treatment guidelines
• National Guideline Clearinghouse: www.guideline.gov
(2700?); EG: American Academy of Neurology has 58,
“Symptomatic Treatment For Muscle Cramps”
• Some are better than others; Institute of Medicine of the
National Academies, “Clinical Practice Guidelines We can
Trust;” March 2011, www.iom.edu
• Evidence-based medicine: levels of evidence for primary
research question; I-V, from most to least rigorous
• Where does your medical treatment guideline fall?
Utilization Review
URAC
• Utilization management standards (procedural: how is UR done)
• www.urac.org “URAC, an independent, nonprofit organization …
accreditation, education and measurement programs.”
• Where do I get the URAC standards?:
http://insurance.illinois.gov/URO/WorkersCompUMStdsv50.pdf
• Standard WCUM 14: Peer review must be conducted by person who holds
valid license in “same licensure category” as the ordering provider (Pg. 70)
• Standard WCUM 17: Review determination must be made within 72 hours
for urgent care, 15 days for non-urgent care (Pg. 72)
• Definition: “Case involving Urgent Care”: 1) serious jeopardy to life or
health or regaining of maximum function ; or 2) severe pain in the opinion
of the physician with knowledge (Page 21)
Utilization Review
Section 8.7, added to subsec. (i)
•
•
•
•
•
(i) Upon receipt of written notice that the employer or the employer's agent or insurer wishes to invoke
the utilization review process, the provider of medical, surgical, or hospital services shall submit to the
utilization review, following accredited procedural guidelines.
(1) The provider shall make reasonable efforts to provide timely and complete reports of clinical
information needed to support a request for treatment. If the provider fails to make such reasonable
efforts, the charges for the treatment or service may not be compensable nor collectible by the provider
or claimant from the employer, the employer's agent, or the employee. The reporting obligations of
providers shall not be unreasonable or unduly burdensome.
(2) Written notice of utilization review decisions, including the clinical rationale for certification or noncertification and references to applicable standards of care or evidence-based medical guidelines, shall be
furnished to the provider and employee.
(3) An employer may only deny payment of or refuse to authorize payment of medical services rendered
or proposed to be rendered on the grounds that the extent and scope of medical treatment is excessive
and unnecessary in compliance with an accredited utilization review program under this Section.
(4) When a payment for medical services has been denied or not authorized by an employer or when
authorization for medical services is denied pursuant to utilization review, the employee has the burden
of proof to show by a preponderance of the evidence that a variance from the standards of care used by
the person or entity performing the utilization review pursuant to subsection (a) is reasonably required
to cure or relieve the effects of his or her injury.
Utilization Review
Provider Obligation & Payment
• Added to Section 8.7: (i) Upon receipt of written notice that the employer
or the employer's agent or insurer wishes to invoke the utilization review
process, the provider of medical, surgical, or hospital services shall submit
to the utilization review, following accredited procedural guidelines.
• (1) The provider shall make reasonable efforts to provide timely and
complete reports of clinical information needed to support a request for
treatment. If the provider fails to make such reasonable efforts, the
charges for the treatment or service may not be compensable nor
collectible by the provider or claimant from the employer, the employer's
agent, or the employee. The reporting obligations of providers shall not
be unreasonable or unduly burdensome.
• Is “no payment” penalty mandatory? “may not be compensable nor
collectible”
• Who decides if “the provider fails to make such reasonable efforts”?
IWCC makes this decision
• What is reasonable, unreasonable, unduly burdensome? Look to URAC
procedural guidelines; expert testimony about URAC (EG, PEER TO PEER)
Utilization Review
Required in Necessity Dispute?
• 8.7(i) “(2) Written notice of utilization review decisions, including
the clinical rationale for certification or non-certification and
references to applicable standards of care or evidence-based
medical guidelines, shall be furnished to the provider and
employee.”
• Impact: Already required by URAC, WCUM 22 (pg. 74)
• 8.7(i) “(3) An employer may only deny payment of or refuse to
authorize payment of medical services rendered or proposed to be
rendered on the grounds that the extent and scope of medical
treatment is excessive and unnecessary in compliance with an
accredited utilization review program under this Section.”
• Impact: Necessity must be disputed with UR; IME alone insufficient
to dispute necessity; careful practitioners will be wary of waiver of
necessity defense; be careful of penalties for unreasonable (by law)
defense (necessity dispute without UR)
Utilization Review
Burden of Proof
• 8.7(i): “(4) When a payment for medical services has been denied
or not authorized by an employer or when authorization for
medical services is denied pursuant to utilization review, the
employee has the burden of proof to show by a preponderance of
the evidence that a variance from the standards of care used by
the person or entity performing the utilization review pursuant to
subsection (a) is reasonably required to cure or relieve the effects
of his or her injury.”
• Impact: “When”: always; UR is required to dispute necessity
• Impact: “Burden of proof”: No change; EMPLOYEE HAS ALWAYS
HAD BURDEN OF PROOF OF NECESSITY
• Impact: “Variance from standards of care”: No change; EG:
Treatment plan different from ACOEM (18 rather than 12 PT’s); Yes,
why would Petitioner try case if agrees with ACOEM
• Impact: “Reasonably required…”: No change; straight out of 8(a)
Utilization Review
Depositions
•
•
•
8.7(i) “(5) The medical professional responsible for review in the final stage of utilization
review or appeal must be available in this State for interview or deposition; or must be
available for deposition by telephone, video conference, or other remote electronic means.
A medical professional who works or resides in this State or outside of this State may comply
with this requirement by making himself or herself available for an interview or deposition in
person or by making himself or herself available by telephone, video conference, or other
remote electronic means. The remote interview or deposition shall be conducted in a fair,
open, and cost-effective manner. The expense of interview and the deposition method shall
be paid by the employer. The deponent shall be in the presence of the officer administering
the oath and recording the deposition, unless otherwise agreed by the parties. Any exhibits
or other demonstrative evidence to be presented to the deponent by any party at the
deposition shall be provided to the officer administering the oath and all other parties within
a reasonable period of time prior to the deposition. Nothing shall prohibit any party from
being with the deponent during the deposition, at that party's expense; provided, however,
that a party attending a deposition shall give written notice of that party's intention to
appear at the deposition to all other parties within a reasonable time prior to the
deposition.”
Impact: A lot more depositions of UR experts; a lot more litigation over dedimus to take UR
expert’s deposition
Impact : Interaction with Rule 7030.60 & Section 16?
Utilization Review
Consideration & Weight
•
•
•
•
•
•
8.7 (i): An admissible A utilization review shall will be considered by the Commission, along
with all other evidence and in the same manner as all other evidence, and must be addressed
along with all other evidence in the determination of the reasonableness and necessity of the
medical bills or treatment. Nothing in this Section shall be construed to diminish the rights of
employees to reasonable and necessary medical treatment or employee choice of health
care provider under Section 8(a) or the rights of employers to medical examinations under
Section 12.
Impact: “An admissible”; Confirms that UR’s not generally admissible or automatically
admissible, supported by deposition provision
Impact: “Shall”; No reason to believe that admitted evidence was not being considered
previously; does not change weight of UR; still NO presumption or determinant or conclusive
effect
See Noemi Solis v. Hospitality Staffing, 11 IWCC 792: Commission affirms Arbitrator’s decision
that NO GREATER WEIGHT given to UR
See Executive Mailing Service v. IWCC, Rule 23, No.1-10-1014WC, 6-27-11: “clearly not
special evidence entitled to greater weight”
Impact: “Must be addressed”; all admitted evidence must be (always should be) addressed;
careful practitioners will do so in proposed decisions
Utilization Review
Case Summaries (Win A Few, Lose A Few)
– Venable v. United Airlines, 08 W.C. 047340
• UR rejected since purported to impose California standards in Illinois
– Chamorro v. Workforce Staffing, 09 I.W.C.C. 55
• UR unpersuasive since answered biased questions posited by employer
and misconstrued basic facts of the case, i.e., non-compliant with URAC
guidelines
– Salgado v. Cardone Record Service, 09 I.W.C.C. 171
• UR adopted to limit chiropractic care to 6 visits
– Garcia v. Executive Mailing Service, 09 I.W.C.C. 0310
• UR was rejected since efficacy requirement too restrictive for the
proposed treatment – discogram and intradiscal electrothermic therapy
– Jackson v. City of Springfield, 09 I.W.C.C. 1124
• UR adopted to find that 3 to 5 of 68 chiropractic visits were medically
necessary
– Cantua v. United Airlines, 09 W.C. 041232
– Ramirez v. Gill Management, Inc., 10 I.W.C.C. 0141
• UR adopted to find that only 10 chiropractic visits were medically
necessary
• UR adopted to deny discogram
Utilization Review
Case Summaries
– Masso v. Frontline Transportation, 10 I.W.C.C. 0314
• UR adopted to find six chiropractic visits reasonable; Commission
rejected arbitrator’s concern that UR could deny necessary
prospective medical care
– Vadakin v. Subway, 10 I.W.C.C. 0414
• UR that did not include a written report was rejected
– Keafer v. City of Kincaid ,10 I.W.C.C. 0707
• UR adopted to find prospective fusion medically unnecessary
– Gomez v. Juno Mfg., 10 I.W.C.C. 1256
• UR adopted to find 3-5 weeks of a 10 month period of chiropractic
care was medically necessary
– Escatel v. Civil Contractors, 10 IWCC 1255
• UR adopted to find that medical providers billed for unreasonable
and excessive care
– Barlow v. Johnny’s Restaurant, 10 IWCC 1291
• UR results and objective testing established that elbow surgery
was not medically necessary
Utilization Review
Case Summaries
– Noemi Solis v. Hospitality Staffing Solutions, 11 I.W.C.C. 792
• UR not persuasive because it ignores the complexity of the injuries
– Rosales v. Robert W. Hendricksen Co., 11 I.W.C.C. 776
• UR rejected given apparent confusion over location of symptoms –
left vs. right
– Carpenter v. State of Illinois, State Retirement System, 11 I.W.C.C. 798
• UR rejected since opined on causation
– Coor v. Lagrou Distribution, 11 I.W.C.C. 0660
• UR adopted to support IME finding of MMI
– Wilcox v. Professional Transportation, 11 I.W.C.C. 0544
• UR rejected since failed to consider full medical records
Utilization Review
Case Summaries
– Medrano v. Scholoss Co., 11 I.W.C.C. 919
• UR adopted to determine final date for medically necessary care
– Melvan, v. Holcim Cement, 11 I.W.C.C. 819
• UR rejected since conclusions mirrored employer’s unsuccessful
19(b) hearing arguments
– Bonadonna v. Wings Program, Inc., 11 I.W.C.C. 448
• UR rejected since UR doctor’s testimony revealed bias to limit
treatment in conflict with the ODG
– Hamilton v. David Renshaw D/B/A Dairy Queen, 11 I.W.C.C. 226
• UR unpersuasive since “internally inconsistent” and because the
UR doctor not registered or certified to perform a UR
– Lorena v. Elite Staffing, Inc., 11 I.W.C.C. 0494
• UR rejected since failed to address significant medical evidence
and reference guidelines
– King v. RGIS Inventory Specialists, 11 I.W.C.C. 0579
• UR unpersuasive since based solely on one IME and did not
consider the treatment records
Utilization Review
Case Summaries
– Pinnell v. State of Illinois, Department of Transportation, 11 I.W.C.C. 0218
• UR declined to certify massage therapy as well as use of prescription
medications; employer not liable for treatments that URs (conducted by
two board certified orthopedic surgeons) did not certify
– Avila v. Elite Staffing, 11 I.W.C.C. 0217
• Treatment prescribed by doctor found medically necessary though
contrary to UR findings; ordering physician’s opinion more credible given
UR’s qualifications and the UR’s lack of response to the ordering
physician’s opinion
– Mejia v. Ron’s Staffing, 11 I.W.C.C. 0164
• UR certified only 6 of 107 chiropractic visits. Arbitrator found no credible
medical basis to justify all the chiropractic treatments and PT relying on
UR
– Fernandez v. ADP Total Source/ H.R. Slater Co., 11 I.W.C.C. 0164
• UR non-certification of recommended lumbar-fusion, citing the need for
multiple issues to be addressed pre-operatively, ordering doctor failure to
appeal, and opinion of IME physician resulted in denial of surgery
Utilization Review in Illinois
November 2011
Overview
Utilization Review - history
State of Illinois requirements of URO
URAC Standards
Types of Review / URAC Process/Timeframes
Guidelines – Evidence-based Medicine
Arbitrator Feedback
Review UR determinations closely
Request Attorney Packet from UR
CorVel contact information
© 2011 CorVel Corporation.
Utilization review is NOT new
Medicare
Medicaid
HMO plans
PPO Plans
Slowly states have begun to adopt this practice for
workers’ compensation cases
© 2011 CorVel Corporation.
Why was UR instituted?
Abuses
Overuse of testing
Inappropriate testing for diagnosis
Inappropriate hospital stays
Lengthy hospital stays
Medical studies – that physicians rely on – have
always been around to help physicians – specialty
organizations decide on treatment
© 2011 CorVel Corporation.
State of Illinois requires companies who
perform UR
UROs are required to follow the URAC standards
“sufficient to achieve URAC accreditation” (820 ILCS
305/8/7)
“Nothing in this Act shall be construed to require an
employer or insurer or its subcontractors to become
URAC accredited.” (820 ILCS 305/87)
Must register and apply for certification with the State of
IL every 2 years.
© 2011 CorVel Corporation.
URAC and its Standards (WCUM)
“Protector of the Utilization Process” Originally URAC was
incorporated under the name Utilization Review Accreditation
Commission” – the name was shortened to just the acronym
“URAC”
Accreditation serves as a symbol of excellence in the health
care industry
The standards apply to the utilization management process
when it occurs in a workers’ compensation setting
There are CORE Standards and WCUM standards - primary
element has direct & significant impact on the welfare and
safety of consumers/patients. The secondary element is
desirable of a high quality program but does not have a direct
impact on welfare and safety of consumers
© 2011 CorVel Corporation.
Utilization Review
Types
Process
© 2011 CorVel Corporation.
Types of Utilization Review
Prospective reviews (pre-certs)
Concurrent reviews (ongoing treatment)
Retrospective reviews (treatment has been rendered)
© 2011 CorVel Corporation.
UR Process
Initial Review
The nurse receives the request for review and medical records
If additional records are required, the nurse can contact the
provider
Nurse reviews the medical records and the treatment under review
Applies to ODG guidelines
Certifies if treatment is appropriate
Informs the provider by phone of the certification
Sends certification letters to provider, injured employee, attorney,
adjuster
If the treatment does not meet guidelines
© 2011 CorVel Corporation.
UR Process – when guidelines not met
The UR nurse refers to Clinical Peer Reviewer
Utilizing evidence based medicine and nationally
recognized guidelines, the Clinical Peer Reviewer
(medical doctor) reviews & provides a UR
determination
Based on Peer decision, the Certification or NonCertification Letters are sent to all parties
Appeal process and peer report are sent with all noncertifications
© 2011 CorVel Corporation.
Clinical Peer Reviewer
Licensed doctor of medicine or doctor of osteopathic
medicine
or
Licensed health professional in the same licensure
category as the ordering provider
or
Health professional with the same clinical education as
the ordering provider in clinical specialties where
licensure is not issued
© 2011 CorVel Corporation.
Peer-to-Peer Conversations
Clinical Peer must be available to discuss review
determinations with the treating provider
Requested by treating provider
Purpose: allows treating provider a chance to discuss a
UM determination before the initiation of the appeal
process. (hopefully avoiding need for formal and
adversarial appeal process)
© 2011 CorVel Corporation.
Appeal process
30 days to Appeal
UR Organization receives appeal request via fax or
phone - can be made by treating provider, injured
employee, attorney
Sent to Clinical Peer Reviewer w/ any addl medical info
Nurse sends out Cert or Non-Cert Ltr based on Peer
determination
2 types of appeals: expedited and standard
Right to standard appeal, if utilized expedited
© 2011 CorVel Corporation.
Clinical Peer Reviewer for Appeals
Hold an active, unrestricted license to practice medicine
or a health profession
Must be Board-certified
Are in the same profession and in a similar specialty as
typically manages the medical condition
Are neither the individual who made the original noncertification, nor the subordinate of such individual
© 2011 CorVel Corporation.
Administrative Non-Cert
For lack of medical records
UR calls provider requesting records
Calls 2nd day requesting same
3rd day sends out Non-Cert for Lack of Medical Records
Once records received – UR process continued
© 2011 CorVel Corporation.
Guidelines utilized by Nurses and Peer
Physicians – Nationally Recognized
ODG, ACOEM, Milliman-Roberts, Interqual
Best practice, evidence-based medicine
Evidence-based recommendations are based on valid
scientific outcomes research, preferably research that has
been published in peer reviewed scientific journals.
Evidence-based information can be used to develop
protocols, pathways, standards of care or clinical practice
guidelines and related educational materials
ODG updated regularly at 3 month, 6 month or yearly
episodes
© 2011 CorVel Corporation.
Physicians utilize evidence-based
medicine – what is evidence-based
medicine?
The practice of evidence-based medicine means integrating
individual clinical expertise with the best available external
clinical evidence from systematic research.
Physicians arrive at medical decisions by relying on
standards of care and individual clinical experience:
 Without clinical expertise, practice risks becoming
tyrannized by evidence, for even excellent external
evidence may be inapplicable to or inappropriate for an
individual patient
 Without current best evidence, practice risks becoming
rapidly out of date, to the detriment of patients
© 2011 CorVel Corporation.
Timeframes to Complete UR Review
Per URAC:
CorVel Timeframes:
PROSPECTIVE REVIEW:
Initial review 72 for urgent care*
15 calendar days for Non-Urgent Care
Prospective Review: 3-5 days
Concurrent Review: 3-5 days
Concurrent Review:
Initial review 24 hours for Urgent care*
Retrospective Review:
15 calendar days for Non-Urgent Care
Retrospective Review:
Dependent on volume of records; number of
treatments being reviewed – anywhere from 1530 days
Within 30 Calendar Days (May be Extended 15 days
if Necessary)
Appeals:
Appeal Timeframes:
Expedited: as per URAC
Expedited: completed with verbal notification within 72
hrs of the request, followed by written confirmation within
3 calendar days
Standard: completed with written notification within 30
calendar days from receipt of request for appeal
© 2011 CorVel Corporation.
Standard: within 30 days; rushed 10 days
dependent on volume
How is the Treating provider contacted?
Notified by Phone
Followed up with a letter of certification
Non-certification letters include the Appeals Process
and Peer Report
© 2011 CorVel Corporation.
Arbitrator Feedback - Comments
Arbitrators comments:
Litigator’s tool – just delays treatment
Out-of-state Peers – not “local” medicine
Credibility of Peer Physician – CVs are important
Response to Arbitrators:
If UR performed appropriately and within appropriate
timeframes with cooperation of treating provider – it
does not delay treatment
Medicine is national / international – physicians rely on
same medical standards; very competent physicians in
all states
Need to send appropriately to UR
UR 4 p.t. visits – not appropriate
Guidelines – “cookbook” medicine; developed by
who? Occ med?
Peer Physician – occ med – reviewing Specialist
(Ortho) recommendations
Guidelines were developed by physicians,
specialists based on standards of care
Peer physicians should be specialty to specialty
– again appropriateness of reviewing company
Disconnect between URO and Defense Attorneys
Attorneys require URO certification, CV of peer,
peer report, non-cert letters, etc.
Hearsay
Peer reports are now sent to treating providers –
helping to eliminate the complaint of hearsay
© 2011 CorVel Corporation.
Utilization Review is Beneficial
Avoids unnecessary surgery
 2nd or 3rd or 4th surgeries
Promotes discussion between physicians on
controversial treatment
Patient is not a candidate
Experimental
Success rate
Serves the patient if utilized appropriately
© 2011 CorVel Corporation.
Review the UR determination closely
Is the non-cert due to poor documentation of the
treating provider?
Is the non-cert for a minimal amount of p.t. visits?
Did the URO have the correct medicals in order to
process UR?
 MRIs
are needed to review for appropriateness of
surgery
If there is a case manager on the case, ask the nurse to
closely review the rationale for non-cert
URO should have QA’d the peer report for accuracy
© 2011 CorVel Corporation.
Encourage your clients to:
Refer to UR prospectively, concurrently
Notify the provider in writing upon acceptance of the
claim that utilization review is utilized on certain
treatment
Follow the process – allow appeals, peer-to-peer
conversations
© 2011 CorVel Corporation.
Call CorVel UR to Request an “Attorney
Packet”
CorVel’s State of IL certification
URAC Accreditation certificate
UR non-certification letter
Peer Report & Peer CV
Appeal confirmation
Appeal determination, Peer Report & Peer CV
Reports on Peer-to-Peer conversations
© 2011 CorVel Corporation.
CorVel UR – Contact and Referral
Information
Jenny Weber, RN, UR Supervisor
Phone: 630-874-7357
e-mail: [email protected]
Complete referral form – in packet
E-mail: [email protected]
Questions for referral: Kim Lindholm at
630-874-7362
© 2011 CorVel Corporation.
Questions?
© 2011 CorVel Corporation.