Transcript MDMCPowerpoint

MEDICAL UTILIZATION
REVIEW (“MUR”)
Presented by:
Nancy A. Fitzgerald, RN, BSN, JD
303-293-8800
[email protected]
. . . what you always wanted to know
about an MUR (really?) but were afraid
to ask.
Part I: The Six W’s of MURs
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#1: WHAT is an MUR?
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#2: WHERE do you find MUR information?
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#3: WHY would a “party” request an MUR?
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#4: WHO are the key players in an MUR?
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#5: WHEN is an MUR decided?
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#6: WOW (or What does an MUR cost)?
#1: WHAT is an MUR?
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An MUR is a statutory means within the Division of Workers’
Compensation by which a “party” can request that the care/service
provided by an “authorized provider” be reviewed by a committee of
three “peer professionals” to determine whether such care/service is
reasonably necessary and/or reasonably appropriate according to
accepted professional standards.
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If the committee determines that the care/service is not reasonably
necessary or appropriate by a majority or unanimous vote, the Director
must order:
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A change of provider (majority vote); and possibly
Retroactive reimbursement for services rendered from a particular date
(unanimous vote); and possibly
Revocation of the provider’s accreditation (unanimous vote for injuries after
7/1/91).
W.C.R.P 10; C.R.S. §8-43-501(1), -503(1).
#2: WHERE do you find MUR information?
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The Act:
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W.C.R.P. 10: provides step-by-step instructions to file a request for an MUR (handout)
Pertinent Case Law:
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C.R.S. § 8-43-503: provides the purpose of an MUR (handout)
The Rules:
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C.R.S. § 8-43-501: sets forth the “mechanism” in a narrative fashion (handout)
Rook v. ICAO, 111 P.3d 549, 552-53 (Colo. App. 2005) (a registered nurse, who may have been the insurer’s
employee, may prepare the medical report required under C.R.S. § 8-43-501(2)(b))
Secondary Sources:
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Craig C. Eley, Medical Utilization Review Under Worker’s Compensation, 17 U. Colo. L. Rev. 1995 (1988):
summary of SB 106, which established the MUR mechanism
WC Website: http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDLEWorkComp%2FCDLELayout&cid=1251567882354&pagename=CDLEWrapper
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http://www.coworkforce.com/dwc/PUBS/ur2002.pdf (Utilization Review Program pamphlet handout)
Other Resources:
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Nancy Fitzgerald: [email protected], (303) 293-8800
Kristin Caruso: [email protected], (303) 861-7760
#3: WHY would a “party” request an MUR?
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An insurer or self-insured employer generally requests an MUR
because that party suspects, in its humble and unprofessional
opinion, that the care/service by one or more current providers
is no longer “reasonably necessary or reasonably appropriate
according to accepted professional standards.” C.R.S. § 8-43501(1) (2).
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In other words, that party suspects its
money is not being used “to cure and
relieve an employee from the effects
of an on-the-job injury.”
C.R.S. § 8-43-501(1).
#3: WHY would a “party” request an MUR?
(continued)
■ Claimant may initiate an MUR if a prior request
to have a personal physician or chiropractor
provide care was denied. C.R.S. § 8-43-501
(2)(c).
#4: WHO are the key players in an MUR?
■ The “Party” requesting the MUR
» Insurer, Self-Insured Employer or Claimant.
■ The “Provider Under Review” (“PUR”)
» Medical doctor, Chiropractor, Dentist, Psychologist, etc.
■ The “Licensed Medical Professional” retained to
prepare the case report
■ The “Committee” appointed to opine whether the
care/service is reasonably necessary or reasonably
appropriate
#5: WHEN is an MUR decided?
■ Some time periods in the MUR process are specified,
others are not.
■ For example, Committee Members are not given a
deadline to complete their review.
■ Generally, from start (submission) to finish
(Director’s Order), an MUR takes about five to six
months, but the entire process can take six to twelve
months. Appeal would likely add another six to
twelve months.
» See Sample Timeline (handout)
#6: WOW – What Does an MUR Cost?
■ MUR Fee
$1,250
■ Case Report:
$5,000 to $8,000
■ Package Preparation:
» Total (estimate)
$1,000 to $1,500
$7,250 to 10,750
A Typical MUR
How to Prove Medical Care/Services is
Unreasonable/Unnecessary
A Typical MUR – Trigger
■ Trigger: Multiple inquiries re: status and
multiple IMEs re: the PUR’s care/services
» Must prove that care was NOT reasonably necessary
to cure and relieve the effects of the injury; or
» NOT reasonably appropriate according to
professional standards to cure and relieve the effects
of the injury
A Typical MUR – The Information Package
(One Copy)
■ Request Form (handout): Request for Utilization Review – 1 page
form identifying the party requesting review and the authorized
physician to be reviewed
■ Copies of all admissions and/or orders filed or entered in the case
■ List of full names and medical degrees of all providers, other
treating providers, and all consultants, IME’s, referrals
■ Fee of $1,250 payable to the Division
Rule 10-2
A Typical MUR – The Medical Records
Package (Seven Copies)
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Table of Contents
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Case Report by a licensed medical professional – dated within 30-days of
the submission
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Records – in chronological order in the following identified sections
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1. Employer’s First Report of Injury and/or Worker’s Claim for Compensation
Form
2. All records from PUR
3. All records from other treating physicians
4. All records from referrals, consults, IMEs
5. All test results
6. All medical management reports
7. All hospital/clinic records
Rule 10-2
A Typical MUR – The Case Report
■ LIMITED to the following, pursuant to C.R.S. § 8-43501(2)(b)
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Name, discipline of care, and specialty of PUR;
Claimant’s standard demographic info (age, sex, marital status, etc.);
Claimant’s employer and occupation/job title, dates of work related
injury/exposure(s);
Date of initial treatment by the PUR and a brief chronological history of
treatment to present, and “any significant contributing factors which may have
had an effect on the length of treatment”; and
A brief statement from the medical professional in support of utilization review.
Unreasonable/Unnecessary Medical Care/Service
(Sample Case 1)
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1990: Claimant sustains a work-related back injury (repetitive bending, twisting, lifting as a
kitchen/counter worker at a fast food restaurant)
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1990’s: Claimant’s addictive personality is noted and back pain is treated with steroid injections,
some narcotics (Darvocet N100 and Vicodin at times), PT, acupuncture, massage, psychiatric
counseling/treatment, and psychotherapy, but Claimant able to work full time as an assistant
property manager
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2002: Initial evaluation by PUR; OxyContin prescribed and Vicodin restarted
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2002-2005: Narcotic use escalates and function decreases; PUR prescribes Actiq lollipops in
2004 and Claimant stops working that same year; narcotic side effects (depression, sleep
disturbances, constipation/bowel obstructions) require additional treatment; opioid habituation
diagnosed by PUR in 2005 and PUR weans Claimant to Percocet for pain control
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2005: Insurer IME: Claimant capable of working full time with restrictions
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2006: Claimant requests additional pain medication and PUR restarts OxyContin
Unreasonable/Unnecessary Medical Care/Service
(Sample Case 1 - Continued)
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2007: Insurer requests status report from PUR, who acknowledges need to wean patient off all
opioid medications
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2007: Insurer IME: Claimant should be evaluated for maintenance care and medications should
be reduced
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2007-2010: Narcotic use re-escalates and DIME indicates too many medications and no
improvement in two years despite multiple therapies
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2009: Pharmacy records document narcotic use
Unreasonable/Unnecessary Medical Care/Service
(Sample Case 1 - Continued)
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2009 Narcotic Prescriptions
1/10/09
1/15/09
2/8/09
3/5/09
4/2/09
4/3/09
4/30/09
4/30/09
5/28/09
5/28/09
5/29/09
6/22/09
6/22/09
6/22/09
7/17/09
7/20/09
7/20/09
7/20/09
8/18/09
8/18/09
8/18/09
9/23/09
9/23/09
9/23/09
10/19/09
10/19/09
10/24/09
11/16/09
11/16/09
12/15/09
12/15/09
12/15/09
Oxycodone 15 mg
Hydrocodone/APAP 10/325
Hydrocodone/APAP 10/325
Actiq lozenges 0.8 mg
Hydrocodone/APAP 10/325
Hydromorphone 4 mg
Hydromorphone 4 mg
Actiq lozenges 0.8 mg
Actiq lozenges 0.8 mg
Hydromorphone 4 mg
Actiq lozenges 0.8 mg
Actiq lozenges 0.8 mg
Opana ER 10 mg
Hydrocodone/APAP 10/325
Hydrocodone/APAP 10/325
Hydromorphone 8 mg
Actiq lozenges 0.8 mg
Opana ER 10 mg
Hydrocodone/APAP 10/325
Fentenyl Transdermal 25 mcg/hr
Actiq lozenges 0.8 mg
Actiq lozenges 0.8 mg
Fentenyl Transdermal 50 mcg/hr
Hydrocodone/APAP 10/325
OxyContin Ter 40 mg
Hydrocodone/APAP 10/325
Actiq lozenges 0.8 mg
Actiq lozenges 0.8 mg
OxyContin Ter 40 mg
Actiq lozenges 0.8 mg
Hydrocodone/APAP 10/325
OxyContin Ter 40 mg
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Unreasonable/Unnecessary Medical Care/Service
(Sample Case 1 - Continued)
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March, 2010: Insurer Pharm. D. IME concludes opioid use should be tapered based on review of
Claimant’s medical and pharmaceutical records
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July, 2010: Insurer IME (record review) concludes recent increased Actiq dose not medically
necessary and PT and sleep study not reasonably necessary
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August, 2010: Insurer IME (record review) concludes PUR’s treatment inconsistent with the
Colorado Workers’ Compensation Medical Treatment Guidelines, clinically inappropriate, and
dangerous to the patient; recommended care be transferred to another provider, and narcotic use
discontinued
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October-December, 2010: Insurer IME (record review) concludes re-starting Claimant on
narcotics is medically inappropriate
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March, 2012: Insurer IME (record review): recommends weaning off all narcotics.
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May, 2012: MUR submitted
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Oct., 2012: Change of provider ordered.
Unreasonable/Unnecessary Medical Care/Service
(Sample Case 2)
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1/03: PUR first sees Claimant for psychiatric therapy related to a work injury that occurred in
1998
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2003-2012: PUR continues to see Claimant 2-4 times per month and prescribe multiple
psychotropic medications, despite repeated documentation of little to no progress
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2003-2010: PUR provides “summary” notes rather than individual therapy notes. For example,
PUR’s “therapy notes” for the entire month of July, 2006 (3 visits) state: “Summary – July 2006:
improved physical condition . . . but complaints of fatigue and depression.” Despite these brief
notes, the PUR prescribed and/or refilled multiple medications in July, 2006, including
Wellbutrin, Lorazepam, Paxil, Cyclobenzaprine, Dantrolene, Oxycodone, and Avinza.
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1/12: Opiate-related liver problems noted
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5/12: Insurer psychiatric IME: PUR’s treatment, although possibly beneficial, “does not comply
with Guidelines because it does not show evidence of progress or recent reassessment and there is
no indication of the services provided, when the services were provided, or what medications are
being prescribed.” IME recommended a neuropsych evaluation.
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6/12: PUR provides insurer with a list of diagnoses and a treatment plan; disagrees with
recommendation for a neuropsych evaluation
Unreasonable/Unnecessary Medical Care/Service
(Sample Case 2 - Continued)
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9/12: Insurer IME (record review): PUR’s record keeping has improved and PUR should not be
changed if psychotherapy is warranted; continues to recommend a neuropsych evaluation
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10/12: Insurer IME: recommended neuropsych evaluation to have a “fresh set of eyes” evaluate
care
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11/12: Insurer IME (record review): epidural steroid injections not medically indicated
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12/12: Insurer requests progress report from PUR, who continues to recommend individual
psychotherapy while at the same time noting that Claimant’s condition continues to deteriorate
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2/13: Insurer IME (record review): agreed that a “fresh set of eyes” was warranted because
Claimant not improving despite individual psychotherapy and multiple treatment modalities
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4/13: MUR submitted
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8/13: Change of provider ordered.
MUR Outcomes
■ Change of Provider Ordered and No Appeal
» C.R.S. § 8-43-501(4): claimant and insurer/self insured
employer must agree on a new provider within 7 days; if no
agreement, Director selects three possible providers and
requesting party selects new provider
■ No Change of Provider Ordered and No Appeal
» PUR continues to provide care and insurer/self insured
employer continue to document issues related to care
■ Appeal: File appeal form with the MUR coordinator within 45 days
(if payment of fees retroactively denied, hearing request must be
filed within 30 days)
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Burden: clear and convincing evidence