The Precertification Process of Utilization Review for Workers Compensation

One of the most important parts of medical management of a workers compensation claim is the precertification process within utilization review. Precertification is the process of have certain medical procedures or medical treatments preapproved by the workers comp insurer before the procedure or treatment is started.

The purpose of precertification is to determine the medical necessity of the medical procedure or medical treatment. Precertification protects the employee from unnecessary medical procedures and it gives the insurer the opportunity to verify the medical procedures requested by the treating physician to meet the accepted medical guidelines for the injury. (The accepted medical guidelines normally used are the criteria for medical procedures or medical treatment established by the American Medical Association).

A precertification review is not done for each routine visit the injured employee has with the treating physician. When the treating physician determines a medical procedure or medical treatment is needed, one not routinely included in an office visit, a request for precertification is needed.

13 Examples of When to Request Precertification:

1. Non-emergency hospital admittance

2. Non-emergency surgical procedures

3. Non-emergency outpatient hospital care

4. Physical therapy and occupational therapy

5. Speech, cognitive, rehabilitation and other restorative therapy

6. Diagnostic testing – MRI, CT scan, myelography, EMG, EEG, etc.

7. Durable medical equipment

8. Home health care

9. Psychological testing

10.Chronic pain management

11.Work hardening programs

12.Acupuncture

13.Experimental procedures

Utilization review precertification is normally done by a medical reviewer employed by the insured, a registered nurse (RN) a contracted vendor. The RN makes a medical necessity approval determination after reviewing the medical history of the injured employee. The RN reviews the medical documentation including diagnostic testing, clinical evaluation reports, physical therapy records, the results of any specialized testing in regards to the requested medical procedures.

If the RN determines the medical procedure is appropriate, the treating physician is notified of the approval. If the RN determines the medical procedure is not supported by the medical records, the denial of the procedure is referred to a doctor employed by the insurer or contracted vendor. The insurer’s doctor reviews all the medical information to determine if the requested procedure or treatment is medically necessary and if it is the best option for the employee. If the insurer’s doctor concurs with the RN that the medical procedure should be denied, the treating physician is notified of the reasons the proposed treatment is denied. If the insurer’s doctor disagrees with the RN and concurs with the treating physician, the treating physician is notified the medical procedure is approved.

When a medical procedure is denied, precertification gives the insurer’s doctor and the treating physician an opportunity to discuss the best options for the treatment of the injured employee. The injured employee benefits by receiving an improved treatment plan. Precertification will provide early identification of treatment issues. It allows the medical reviewer to communicate with the workers comp adjuster what the medical issues are and to explain what is/are the employee’s best medical option(s).

An example of the benefits of precertification is the treatment options for low back pain. The admission of employees to the hospital for non-surgical treatment of low back pain was common thirty years ago. Treating physicians would run out of treating options and admit people to the hospital primarily for bed rest. With precertification showing a lack of medical necessity for the hospital admission, this practice is unheard of today.

In addition to providing the injured employee with the best medical option(s) for recovery, precertification has other benefits including lower cost for the employer and promotion of an atmosphere of the best interest of the injured employee.

Precertification determines the medical necessity of medical procedures and medical treatment before the cost is incurred. Precertification is a win-win scenario. It insures the employee is receiving the best medical care for their injury and prevents unnecessary medical care that delays the employee’s recovery. Precertification lowers the overall cost of medical care by eliminating unnecessary medical expense.

Jane Steele, RN, MS, CCM, Nurse Case Manager from Genex Services, points out that one downside to precertification review is that things take forever to get things done…. unless you have a nurse cse mgr who can jump thru the necessary hoops in the system and speed things along.

Copyright © 2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.