Best Practices Hierarchy



Utilization review (UR) and medical bill review (MBR) have long been viewed as a perfect pairing in workers’ compensation. So much so that the need for integration between the two services has been given much attention by service providers.   

Today’s most effective workers’ compensation managed care programs have raised the bar by demanding a more impactful strategy. Fostering a hierarchy of best practices can improve managed care program efficiencies, outcomes, and resulting savings. This hierarchy combines utilization review, medical bill review, and medical nurse case management in a different way. Prioritization of when and how this trio of strategies is integrated matters.

Consider the following facts:

Fact 1: Utilization review is about the patient; medical bill review is about the payment. UR precertification determines whether or not treatment should occur. Medical bill review determines payment recommendation for treatment that has already occurred.

Fact 2: Utilization review and medical nurse case management are synergistic clinical tools. Both UR and nurse case management help ensure the right treatment, the right number of treatments, at the right time, and through the right medical pathway. Medical nurse case managers (NCMs) facilitate appropriate and coordinated treatment and assess injured workers’ response to treatment, helping them achieve optimum pre-injury functional potential or maximum functional independence. NCMs serve as medical liaisons to all stakeholders. As liaisons, they minimize fragmentation of care throughout the course of treatment, avoid delays in appropriate treatment, redirect care when necessary, and set expectations for recovery and return to work.

Fact 3: Savings achieved by integrating UR with bill review can be significantly increased by also integrating UR with case management. Significant UR savings occur upfront through prevention of medically unnecessary treatment. Separately, the bill review process determines if costs billed are appropriate and in accordance with fee schedules and provider network discounts for additional savings. Loading UR determinations, such as non-certified treatment, into the bill review system could drive an additional 0.5-1 percent savings, as bill review could deny payment for unapproved services. However, if UR is simultaneously integrated with medical case management—which are both front-end processes that focus on managing patient care—the savings could increase exponentially and claim results could improve dramatically.

Fact 4: Utilization review decisions may have significant claim consequences, especially when requested treatment is non-certified. When a treatment request is non-certified, the patient and the provider typically have concerns that need to be immediately addressed. The patient wants to know why the “insurance company” or “employer” will not approve care that his doctor tells him he needs. The provider may not agree, or understand, why the treatment request was not certified. This may be a tipping point in the course of the claim that drives the patient to seek representation and/or into a treatment protocol where appropriate alternative care is not received. It’s a time of uneasiness and unnecessary confusion if not handled quickly and carefully. As liaisons, NCMs have the potential to play a critical role in ensuring these types of UR decisions are handled with the open communication and proactive coordination that is necessary. 

Fact 5: Technological integration of UR with nurse case management is essential to timely intervention. UR determinations must be passed on to the NCM immediately in order to yield timely and optimal results. Adjusters with full caseloads may not have the bandwidth to relay this information instantly and consistently every time. Instead, this is a perfect place for programs to apply technology to make UR determinations available promptly and electronically to medical case management. The electronic transmission would occur on the same day that UR decisions are distributed to all other stakeholders. As a result, the best opportunity for proactive case management is not lost. Nurses receive decisions in time to prevent problems and assert control.

Putting Patients First Through Advocacy
As the facts above have shown, when a UR determination is made and communicated to the patient and provider, there’s a critical span of time when NCMs can jump in and make a huge impact on patient outcomes and the claims resolution. As such, UR decisions should be electronically communicated to the NCM at the same time the determination letter is sent to the patient and provider. When this occurs, stakeholders realize the following benefits:

Timely intervention
The case manager can better serve as a medical liaison to all stakeholders and get in front of important communication needs. The nurse will help control perception and next steps, rather than coming in after patient and provider misunderstanding, frustration, delay in care, and dissatisfaction with the experience.

Stakeholder advocacy
—In the presence of certified treatment, the nurse will facilitate scheduling, patient education and understanding, compliance with the treatment plan, and coordination of the next steps in care.

—In the presence of a non-certification of requested treatment, the nurse will immediately intervene to ensure understanding as to why the planned treatment was non-certified. If it’s a matter of the provider office not submitting the correct or complete supporting medical records with the request, the nurse can reassure the patient and also coach the provider about what is missing. If the treatment plan was non-certified because it did not meet standards of care, it is more complicated. The nurse will work with stakeholders to help them recognize the usefulness or limitations of services. The nurse will review the report with the treating provider and will work to ensure that there is an alternative treatment plan in place. Most importantly, the nurse case manager will be a patient advocate. The NCM will discuss the decision and treatment plan with the patient to promote understanding and actively engage the patient in care choices within the complex medical care system.

Improved outcomes
The nurse case manager will help stakeholders obtain answers to medical questions and concerns related to injury and recovery to proactively reduce length and extent of health care needs and to help prevent future complications. A safe and medically appropriate return to work is expedited through a patient-centered, cost-effective, and caring approach.

A Hierarchy to Integration
When evaluating the high impact of pairing UR and medical nurse case management, it is evident that integration of UR with medical case management should occur as a priority in managed care programs. Utilization review combined with effective and timely medical nurse case management influences what will happen well in advance of the provider submitting medical bills.

Utilization review, medical nurse case management and medical bill review are powerful managed care program tools. Workers’ compensation program managers should consider prioritizing the integration and pairing of UR and medical nurse case management as a front-end management strategy. At the same time, UR decisions should also be transmitted to bill review for a back-end payment management strategy, predominantly for services already rendered. This hierarchy of pairing strategies will allow for optimum program outcomes and maximum cost savings.


Amanda Naser is national account manager at Genex Services, the trusted provider of managed care services enabling workers’ compensation payers and risk managers to transform their bottom lines. The company serves 381 of the Fortune 500 companies as well as top workers’ compensation carriers and third-party administrators. Genex is the only company that delivers high-quality clinical services enhanced by intelligent systems and 360-degree data analysis. It consistently drives superior results related to medical, wage loss, and productivity costs associated with workers’ compensation claims.

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This article is a great example of the intricate role the Nurse Case Manager plays in facilitating appropriate treatment for the injured worker. In addition, evidence based medicine has emerged as the best resource for approving or denying treatment. Efficacy of the recommended treatment is essential to knowing whether a treatment recommended is appropriate. Thanks for sharing!

Jason R Wolfe RN MSN CCM BSN

2016 07 07

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