Proper Management of Utilization Reviews by Nurse Case Managers

Utilization review (UR) is a medical management technique to verify medical care is appropriate, adequate and necessary for the treatment of a workers’ compensation injury. Normally, the UR is conducted by a highly experience registered nurse (RN). When the RN does not agree with the medical care being recommended or provided, a physician will review the medical information to verify that a denial of the medical care is appropriate.



Pre-Certification Review


There are three basic types of Utilization Review – pre-certification reviews, concurrent reviews and retrospective reviews. Pre-certification reviews are the type of Utilization Review most employers think of when they hear the term UR. In a pre-certification review, the RN obtains the medical information on the employee’s injury including the symptoms, the diagnosis, any diagnostic testing results and the medical provider’s reason for requesting the specific medical care. The medical information is compared with the normal criteria for treatment of the employee’s specific injury and an approval or denial decision is made.



Concurrent Review


With a concurrent review, the Utilization Review occurs while the injured employee is receiving medical care. Concurrent reviews occur while an employee is still hospitalized or is having a series of medical treatments over a period of time. The same information gathered for a pre-certification review is obtained for the concurrent review. Concurrent reviews frequently shorten the period of time the employee is in the hospital or the time the employee receives repetitive treatments like physical therapy or acupuncture.



Retrospective Review


Retrospective reviews occur after the medical treatment has been provided. The RN will gather all the necessary medical information and make a determination as to whether or not the medical treatment already provided was actually necessary.



Utilization Review Quality Control Criteria


When the employer accesses the claim management system to review the adjuster’s file notes and the nurse case manager’s file notes, there are certain aspects of the Utilization Review that should be documented by either the nurse case manager or the UR nurse. The quality control criteria should reflect the following being completed in regards to Utilization Review:


• Receipt of the Utilization Review request is documented the same day it is received


• The Utilization Review request was given to the UR nurse within a time frame that allows for accurate review of the medical information to determine medical necessity (of course there will be exceptions for when a rush UR is needed, but a rush UR should be the exception, not the normal practice)


• Logging or a tracking diary is established to ensure the Utilization Review is completed within 3 days for pre-certification reviews and concurrent reviews, and within 7 days for retrospective reviews


• All necessary medical information has been provided to the Utilization Review nurse with the UR nurse having access to information on the diagnosis, prior medical procedures, prior medical opinions, diagnostic testing, comorbidities, etc.


• Consideration is given to the Official Disability Guidelines for the employee’s injury type


• If the Utilization Review nurse determines the medical care under review is not necessary, the UR nurse has obtained a concurring opinion from a physician advisor who reviews all the medical information and the UR nurse’s reasons for denial


• The recommendation of the physician advisor is documented by the Utilization Review nurse


• If there is a recommendation of denial of the medical care, the medical provider has been given the opportunity to review the reasons for denial of the medical care and is allowed to provide any additional information the medical provider believes would justify a reversal of the decision to deny the care


• If the medical procedure has been denied, a letter explaining the reasoning for the denial of the medical care is provided to the employee, the medical provider and the adjuster


• If the medical treatment is approved by the UR nurse, the medical provider and the adjuster are notified timely of the Utilization Review determination



Proper procedures by the Utilization Review nurse are the norm, not the exception, as UR nurses know any deviations from established UR procedures can result in costly mistakes. However, it is still a good practice for the employer to review the UR process documented in the claims management system, especially any time the employer has a question about the necessity of an expensive medical procedure.




Author Michael B. Stack, CPA, Principal, Amaxx Risk Solutions, Inc. is an expert in employer communication systems and part of the Amaxx team helping companies reduce their workers compensation costs by 20% to 50%. He is a writer, speaker, and website publisher. Contact:


©2013 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law.



Do not use this information without independent verification. All state laws vary. You should consult with your insurance broker, attorney, or qualified professional about workers comp issues.

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