Utilization Review

You Ain’t From Around These Parts

What is the value of same state licensure for peer reviews in workers’ comp utilization review?
By: | August 12, 2014 • 2 min read

Peer review is used in a lot of different ways to identify physician involvement in claim management. For the purpose of this article, peer review is referred to the necessary process inside of utilization review (UR) that ensures medical necessity denials are made by physicians or other key health care practitioners. But do these peer providers need to be licensed in the jurisdiction of the WC claim?Today, only a few states require physicians to be licensed by their own state medical board in order to perform UR peer reviews. However, each year, additional states discuss same-state license requirements and/or file legislation to mandate same state licensed peer reviewers.

Hannusch MAP

With more states now considering same-state licensure requirements, it appears that many participants believe that this requirement helps ensure high quality peer reviews. But shouldn’t the focus be on ensuring quality peer review and does same state licensure foster this?

A peer reviewer’s most important responsibility is objectivity. Objectivity requires a physician to understand the effect of treatment determinations on claims outcomes. Peer reviewers must provide high quality determinations that are supported and justified in accordance with applicable state requirements.

Is same state license mandate necessary? Does it create a better peer review process?

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To determine whether a peer reviewer has the right attributes to make quality decisions, consider these key points, and assess whether a same-state license would enhance the quality of UR medical necessity decisions.

When you ain’t from around these parts, does it make a difference? Simple answer is NO.

There is no support for the premise that physicians licensed in a state perform better peer reviews for that state. Requiring same-state licensure adds cost and bureaucracy, with no known value to peer review quality. What do we really want from a peer review physician? The key is a doctor who understands evidence-based guidelines and how to improve an injured employee’s quality of life and ability to return to work. What matters is that the peer reviewer serves the injured worker by knowing the applicable state guidelines and processes and being exceptionally qualified medically to review the proposed treatment.

Hannusch CHART NEWRead more to review the facts or myths about the top 10 most commonly heard reasons for peer reviewers to have same state licenses.

Lisa Hannusch is CEO of UniMed Direct and founder of UR Nation. She specializes in the effective management of utilization and medical claim issues. She can be reached at [email protected]

4 Companies That Rocked It by Treating Injured Workers as Equals; Not Adversaries

The 2018 Teddy Award winners built their programs around people, not claims, and offer proof that a worker-centric approach is a smarter way to operate.
By: | October 30, 2018 • 3 min read

Across the workers’ compensation industry, the concept of a worker advocacy model has been around for a while, but has only seen notable adoption in recent years.

Even among those not adopting a formal advocacy approach, mindsets are shifting. Formerly claims-centric programs are becoming worker-centric and it’s a win all around: better outcomes; greater productivity; safer, healthier employees and a stronger bottom line.

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That’s what you’ll see in this month’s issue of Risk & Insurance® when you read the profiles of the four recipients of the 2018 Theodore Roosevelt Workers’ Compensation and Disability Management Award, sponsored by PMA Companies. These four programs put workers front and center in everything they do.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top,” said Steve Legg, director of risk management for Starbucks.

Starbucks put claims reporting in the hands of its partners, an exemplary act of trust. The coffee company also put itself in workers’ shoes to identify and remove points of friction.

That led to a call center run by Starbucks’ TPA and a dedicated telephonic case management team so that partners can speak to a live person without the frustration of ‘phone tag’ and unanswered questions.

“We were focused on building up a program with an eye on our partner experience. Cost was at the bottom of the list. Doing a better job by our partners was at the top.” — Steve Legg, director of risk management, Starbucks

Starbucks also implemented direct deposit for lost-time pay, eliminating stressful wait times for injured partners, and allowing them to focus on healing.

For Starbucks, as for all of the 2018 Teddy Award winners, the approach is netting measurable results. With higher partner satisfaction, it has seen a 50 percent decrease in litigation.

Teddy winner Main Line Health (MLH) adopted worker advocacy in a way that goes far beyond claims.

Employees who identify and report safety hazards can take credit for their actions by sending out a formal “Employee Safety Message” to nearly 11,000 mailboxes across the organization.

“The recognition is pretty cool,” said Steve Besack, system director, claims management and workers’ compensation for the health system.

MLH also takes a non-adversarial approach to workers with repeat injuries, seeing them as a resource for identifying areas of improvement.

“When you look at ‘repeat offenders’ in an unconventional way, they’re a great asset to the program, not a liability,” said Mike Miller, manager, workers’ compensation and employee safety for MLH.

Teddy winner Monmouth County, N.J. utilizes high-tech motion capture technology to reduce the chance of placing new hires in jobs that are likely to hurt them.

Monmouth County also adopted numerous wellness initiatives that help workers manage their weight and improve their wellbeing overall.

“You should see the looks on their faces when their cholesterol is down, they’ve lost weight and their blood sugar is better. We’ve had people lose 30 and 40 pounds,” said William McGuane, the county’s manager of benefits and workers’ compensation.

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Do these sound like minor program elements? The math says otherwise: Claims severity has plunged from $5.5 million in 2009 to $1.3 million in 2017.

At the University of Pennsylvania, putting workers first means getting out from behind the desk and finding out what each one of them is tasked with, day in, day out — and looking for ways to make each of those tasks safer.

Regular observations across the sprawling campus have resulted in a phenomenal number of process and equipment changes that seem simple on their own, but in combination have created a substantially safer, healthier campus and improved employee morale.

UPenn’s workers’ comp costs, in the seven-digit figures in 2009, have been virtually cut in half.

Risk & Insurance® is proud to honor the work of these four organizations. We hope their stories inspire other organizations to be true partners with the employees they depend on. &

Michelle Kerr is associate editor of Risk & Insurance. She can be reached at [email protected]