• Menu
  • Skip to main content
  • Skip to secondary navigation
  • Skip to primary sidebar
  • Skip to footer

Before Header

  • Search
  • About
  • Contact
  • Privacy
 
CHOOSE BROADSPIRE

Amaxx Workers Comp Blog

Reduce Workers Compensation Costs By 20-50%

Header Right

  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login

Mobile Menu

Choose Broadspire

CHOOSE BROADSPIREBroadspire Delivers Meaningful Results to Our Clients and Their Claimants
  • Home
    • Training Center
  • Get Started
    • Newcomers Class for WC Professionals
    • Subscribe to Free Newsletter
    • Free Training Center Account
    • Return to Work Resources
    • WC Claims Mgmt. Resources
    • Insurance Advisor Resources
  • Membership
    • Insider (free account)
    • WC Mastery
    • Teams & Managers Mastery
    • Training Partners
  • Products
    • On-Demand Courses
    • Specialty Courses
    • Certifications & Mastery Courses
    • Ultimate Guidebooks
  • Blog
    • Video Blogs
    • COVID-19 / Coronavirus Pandemic
  • Login
  • Search
  • About
  • Contact
  • Privacy
You are here: Home / Medical Cost Containment / The Precertification Process of Utilization Review for Workers Compensation

The Precertification Process of Utilization Review for Workers Compensation

December 1, 2010 By //  by Rebecca Shafer, J.D. Leave a Comment

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).

Click Link to Access Free PDF Download

“The 6-Step Process To Determine Workers’ Comp Injury Causation”

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.

FREE DOWNLOAD: “The 6-Step Process To Determine Workers’ Comp Injury Causation”

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.
Author Rebecca Shafer, JD, President of Amaxx Risks Solutions, Inc. is a national expert in the field of workers compensation. She is a writer, speaker and website publisher. Her expertise is working with employers to reduce workers compensation costs, and her clients include airlines, healthcare, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing.
C
ontact:  RShafer@ReduceYourWorkersComp.com or 860-553-6604.
 WORK COMP CALCULATOR:   http://www.LowerWC.com/calculator.php
MODIFIED DUTY CALCULATOR:   http://www.LowerWC.com/transitional-duty-cost-calculator.php
JOIN WC GROUP:  http://www.linkedin.com/groups?homeNewMember=&gid=1922050/
SUBSCRIBE: Workers Comp Resource Center Newsletter
Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker or agent about workers comp issues. 

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

FREE DOWNLOAD: “The 6-Step Process To Determine Workers’ Comp Injury Causation”

Filed Under: Medical Cost Containment Tagged With: Medical Benefits, Medical Issues, Precertification

Related Articles

Kevin Turner Featured in AMAXX Webinar on Catastrophic Workers’ Comp Claim Strategies

Kevin Turner Featured in AMAXX Webinar on Catastrophic Workers’ Comp Claim Strategies

Improve Medical Case Management in Workers’ Comp Claims

Improve Medical Case Management in Workers’ Comp Claims
Field Nurse Case Manager

When to Use a Nurse Case Manager in Your Claim

When to Use a Nurse Case Manager in Your Claim
Nurse case manager

Nurse Case Management Reduces Work Comp Costs and Drives Engagement

Nurse Case Management Reduces Work Comp Costs and Drives Engagement

Independent Study by Actuarial Firm Finds Paradigm Catastrophic Care Management’s Improved Outcomes Managing Workers’ Compensation Claims

Independent Study by Actuarial Firm Finds Paradigm Catastrophic Care Management’s Improved Outcomes Managing Workers’ Compensation Claims

Catastrophically Injured Workers: How to Protect the Most Vulnerable During COVID-19

Catastrophically Injured Workers: How to Protect the Most Vulnerable During COVID-19
Use A Medical Advisor To Maximize Value of Independent Medical Exam

How To Get The Most From An Injured Worker’s Medical Appointment

How To Get The Most From An Injured Worker’s Medical Appointment

Maximize Use of IMEs in Work Comp Cases

Maximize Use of IMEs in Work Comp Cases

How Targeted Behavioral Health Support Keeps Catastrophic Claims on Track for Best Outcomes

How Targeted Behavioral Health Support Keeps Catastrophic Claims on Track for Best Outcomes

Paradigm Deepens Behavioral Health Support for Catastrophically Injured Workers with AiRCare Health Partnership

Paradigm Deepens Behavioral Health Support for Catastrophically Injured Workers with AiRCare Health Partnership

Covid-19 Clinical Management for Injured Workers

Covid-19 Clinical Management for Injured Workers

Paradigm Introduces New First of its Kind COVID-19 Clinical Management Program for Injured Workers

Paradigm Introduces New First of its Kind COVID-19 Clinical Management Program for Injured Workers

Train to Succeed

BECOME CERTIFIED IN WORKERS’ COMPENSATION

Proven Course Catalog & WC Toolbox Give You The Power To Achieve Lower Costs and Better Injured Worker Outcomes

VISIT WORKERS' COMP TRAINING CENTER

Free Download

The 6-Step Process To Determine Workers' Comp Injury Causation - FREE Download Click Here Now!

Previous Post: « Jury Says Former North Dakota Executive Not Dismissed As Whistleblower
Next Post: The Bunkhouse Rule Applies to Employees Living in Employer-Provided Housing »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

FREE DOWNLOAD

The 6-Step Process To Determine Workers' Comp Injury Causation - FREE Download Click Here Now!

Our Sponsors

Broadspire

Workers’ Comp 3rd-Party Administrator
 

Catastrophic Care Management, Complex Care, and Specialty Networks
 

Ametros

Post-Settlement Administration
 

Medcor

Injury Triage, Onsite Clinics

Read Our Award-Winning Blog

Blog Categories

Search Our Archive

Subscribe to Our FREE Newsletter

Footer

Search Our Archive

Search our continually growing archive of over 2500 articles about Workers' Comp issues.

Quiclinks

  • Calculators
  • Terms & Abbreviations
  • Glossary of WC Premium Terms
  • WC Resources
  • Best Practices
  • Industries

RSS Recent Blog Posts

  • Reduce Workers’ Comp Costs in a Union Environment
  • Selecting the Right Service Providers to Reduce Workers’ Comp Costs
  • 3 Techniques To Gain Workers’ Comp Management Commitment
SUBSCRIBE TO OUR FEE NEWSLETTER
Let Us Help You Stomp Down the High Cost of Workers' Comp!
Top of Page ↑
  • Home
  • Training Center
  • Get Started
  • Membership
  • Products
  • Blog
  • About
  • Contact
  • Subscribe
  • Login
Copyright © 2021 Amaxx, LLC. All Rights Reserved. · Privacy Policy / Legal Notice