Telling the Difference Between Medical Management and Utilization Review

For the employee or the employer unfamiliar with workers compensation terminology, the terms medical management and utilization review sound similar. An employee should be accustomed to workers compensation terminology in case of injury and to understand the medical treatment process. The differences between medical management and utilization review should be understood by the employee and the employer alike. While both medical management and utilization review involve the use of a nurse, the two areas are quite different.

Medical management is the coordinating and planning of medical care provided to expedite the employee’s return to work or to help the employee maximize medical improvement. Medical management is normally the responsibility of the nurse case manager (NCM).

Utilization review is the evaluation of medical care being provided to the employee to determine the medical necessity and appropriateness of medical treatment being provided for an injury. The utilization review is conducted by a registered nurse (RN) who has a utilization review physician available for a medical opinion should the nurse be unsure of medical treatment.

8 Responsibilities of the NCM Involved in the Workers Compensation Claim

1. Facilitating the medical rehabilitation of the injured employee.
2. Coordinating the medical care between different providers to achieve the best possible results in a cost-effective manner.
3. Consultation with the medical provider to determine the best treatment plan for the injured employee.
4. Act as a liaison and facilitating the communication between employer, employee, and insurance adjuster.
5. Monitoring the employee’s medical progress.
6. Assisting the employer in identifying the return to work options.
7. Coordinating the employee’s return to work, whether full or modified duty, with the employer, the employee, and the medical provider.
8. Insure utilization review is brought in on all medical care and/or medical services when appropriate

Note: not all NCM is alike – look for providers who use licensed RNs and are URAC Certified. Determine how much clinical experience the NCM’s have — good ones have 3 years minimum clinical experience and 15 years average clinical experience. Senior Nurse Reviewers (SNR) are a higher level of NCM that provides medical oversight on the file the whole way through. The SNR sees the Triage File, Treater File, 3-point contact, and Duration Guidelines.

4 Types of Utilization Reviews Used by the Nurse Involved in the Workers Compensation Claim

1. Pre-certification reviews occur prior to the medical care being provided. The RN collects all the necessary information including the symptoms, diagnosis, results of tests, and the reasons the physician is requesting the medical service. The RN compares the information against the normal criteria for treating a specific type of injury. If the medical care is deemed necessary, it is approved. If the medical service is not necessary, the utilization review physician is asked to verify the denial of the service requested is correct. Nurses use medical guidelines such as MDGuideines which tell the appropriate length of time out of work or disability for any given injury, co-morbidity and even zipcode. Good TPAs have these guidelines at their fingertips.
2. Concurrent reviews occur during the time medical treatment or service is being provided. This can be either for a patient in the hospital or for on-going outpatient care. The RN follows the same approach with the concurrent review as followed in the pre-certification review.
3. Retrospective reviews occur after the medical service has been provided for either an in-patient or out-patient service. The RN again follows the same criteria as with a pre-certification review.
4. Re-reviews occur when the pre-certification review, concurrent review, or retrospective review result in medical care or medical payments being denied. When a re-review is requested, the utilization review physician will go over all the information to determine if the prior decision was or was not correct.

Utilization Review provides an objective opinion as well as a client liaison, to ensure the right treatment is received at the right time based on evidence-based medicine. The review considers medical necessity and sometimes causal relationship to the injury, not cost.

It is in the employers and the insurers best interest to provide both medical management and utilization review on any indemnity claim or enhanced medical only claim. By combining medical management with utilization review, the employee receives the best medical care at the optimum cost. This has a positive impact on the employer’s future workers compensation premiums and builds employee loyalty as the employee feels he or she is given the best possible medical care, a win-win situation for all. It can be very effective to use Nurse Triage at the time of injury, Senior Nurse Reviewer throughout the life of the claim and Utilization Review

Note: All utilization review and medical management providers should be URAC Certified. This rigorous credentialing process has separate categories of for Utilization Review and Nurse Case Management. Your providers should be certified in both areas if they are providing both services. ASK THEM.

Author Rebecca Shafer, JD, President of Amaxx Risk 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. See www.LowerWC.com for more information. Contact: [email protected].

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