The Basics of Workers Compensation Medical Accreditation

With medical cost inflation far exceeding inflation in general over the last two decades, everyone wants to control the cost of medical care. In workers compensation, medical management is justifiably used to control medical care cost. However, when you see the large expense for triage, nurse case management or pharmacy benefit management, do you wonder if you are getting your money’s worth? The answer is an absolute yes — IF you are using highly trained, qualified and skilled medical management firms.

The question then becomes how will you really know if the medical management companies you hire are the highly trained, qualified and skilled medical management companies you need? None of the companies you consider will claim anything else. Fortunately, for workers compensation insurers and self-insured employers, there is a way of knowing – check their accreditation. (open-ended) (WCxKit)

URAC is the largest and best known organization in the medical care accreditation industry. Its purpose is to set the standards for qualification, credentials, and deliverance of health care. URAC’s original name was Utilization Review Accreditation Commission. URAC serves the health care industry in general; not just workers compensation; however it does provide accreditation in several key areas of medical cost management for workers compensation.

Areas of interest to the workers compensation community include: (Note: Being accredited in one category does not mean a company is qualified in any other category.)

1. Nurse Case management.

2. Independent review organizations.

3. Health utilization management.

4. Health call centers (triage).

5. Worker’s compensation utilization management.

6. Pharmacy benefit management.

For accreditation to be worthwhile, it must entail a lot more than a company paying a fee and getting an accreditation seal issued to them. Accreditation must be based on a medical management company meeting strict standards set high enough to ensure competency and expertise in their area of specialization. URAC accomplishes this by developing its standards through committees of experts. The experts come from a broad spectrum of the health care industry including insurers, health care organizations, medical providers, employers, regulators and other areas.

An effective accreditation organization, is independent of any of the parties be accredited. URAC is not owned or controlled by any party being evaluated for accreditation. The company has over 500 committee volunteers — experts from medical providers, employers, insurers, and regulators, plus its paid management staff.

When new standards are added or existing standards changed, URAC provides a copy of the proposed standards to all interested parties. Everyone involved can make recommendations for improvements or clarification in the standards development. All standards are reviewed every three years. If rapid changes/developments in the medical field necessitate a review of standards in a shorter period of time, URAC does so. (open-ended)

Effectiveness of the accreditation standards are ensured by URAC controlling the process with its own guidelines, including:

1. Quantitative measurements.

2. Analysis and reporting of measurements.

3. Surveys to obtain additional input.(WCxKit)

On the URAC website, www.urac.org, you can look up the accreditation of the various medical management companies you use. You can search by either their area of expertise, by their name or by a particular state (California takes a while to load as it is a very long list). If your workers compensation medical management company is not listed, it does not mean they are unqualified, but serves as a warning to further check their qualifications. (Note: Qualifying in one area, like case management, does not mean a company is qualified in another specialty, like triage.)

Make sure to include in your RFP’s that nurse case management, nurse triage, and physician review is URAC certified.