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). (WCxKit)



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. (WCxKit)


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 for more information. Contact:







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.


©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact


Using Utilization Review Programs to Control Narcotic Use in Workers Compensation

Utilization Review: Role of a Pharmacy Benefits Manager (PBM)

As discussed previously, forming a partnership with a PBM can provide workers compensation payors a valuable resource in controlling narcotics use and thereby reducing risk for all stakeholders. There are eight key best practices PBMs can deploy to assist payors. We discuss key best practices five through eight here. See previous discussion for best practices one through four.



Key Bests Practices Five through Eight

#5: Managing Prospective and Concurrent Narcotics Utilization Review Programs

The PBM should have a clinical management process to govern narcotics utilization managed by clinical pharmacists. The clinical drug utilization review (DUR) program should use a combination of evidence-based guidelines, peer review journals and recommendations provided by government organizations. Both prospective and concurrent review processes are essential to a successful program. (WCxKit)



Prospective utilization reviews: A prospective program allows all involved parties to plan for future outcomes with up-front information. Historical data and practices guide future decisions at the establishment of the PBM relationship. This prospective process allows for the achievement of cost control and utilization control.



Concurrent utilization reviews: The PBM triggers concurrent alerts to inform the dispensing pharmacist about possible reasons a prescription should be questioned further prior to filling. These point-of-sale alerts may establish behaviors that could indicate abuse involving the use of multiple pharmacies and physicians for different narcotics or excessive early refill attempts. The messaging from the PBM ensures that prescriptions for narcotics will not be fulfilled at the point-of-sale unless the medication is allowed or the PBM receives authorization from the payor.



#6: Conducting Retrospective Drug Utilization Reviews and Clinical Intervention Programs

Retrospective reviews: After a prescription is fulfilled, a PBM’s clinical pharmacist team should audit these prescriptions for indicators of inappropriate use. Indicators often include:

  •  Sole use of narcotics as treatment.
  •  Multiple physicians.
  •  Use of multiple short or long acting narcotics.
  •  Excessive duration and use.


These types of utilization review programs are essential to maximize the effectiveness of a narcotics usage strategy and are most effective when leveraged in conjunction with prospective and concurrent drug utilization reviews. PBM programs should be flexible enough to allow for customization of review requirements for clients, as client goals and objectives often vary even within organizations.



Physician monitoring: A PBM should continually monitor the use of multiple physicians by one injured worker.


The physician monitoring program should be based on established best practices and contain multiple components including:

  • Monitoring for appropriate medication utilization using evidence-based published therapeutic guidelines.
  • Overseeing prescribing patterns at the physician level to establish appropriate/inappropriate use of brand name medications when an FDA-approved generic equivalent exists.
  • Participating in mandatory and voluntary state reporting programs that monitor for excessive prescribing patterns.


Clinical intervention programs: The PBM should have a range of clinical intervention programs to assist a client with evaluation needs. The range of programs should consist of registered pharmacists, nurses and other health professionals available for consultation on medication questions to more detailed evaluations including peer reviews and direct consultation with prescribing physicians. The PBM’s clinical intervention team should provide recommendations for specific claims that require further evaluation through the use of the information gathered in prospective, concurrent and retrospective review processes.



One example of these recommendations is physician letters of medical necessity. The use of the letter of medical necessity helps to substantiate the treatment of an illness or injury with particular narcotic or adjunctive medication.



If further analysis is required, the PBM should have other program options available. Program options could include a detailed review that contains a summary of the injured worker’s medication history through more in-depth medication evaluation referencing the entire clinical record.



#7: Providing Ongoing Consultation

A quality narcotics utilization program is an essential component of controlling narcotics use. To ensure the utilization program is effective, the pharmacists managing the programs should take proactive measures to continually expand utilization review programs as the workers compensation industry evolves. As changes occur, they should also be available to consult with clients on how to adapt their DUR programs accordingly.



When first released, several powerful narcotics such as Actiq® and Fentora® were developed and prescribed to treat terminal cancer pain. Recently these two narcotics, along with others, have been widely prescribed for lower back pain. An effective PBM should continually expand its DUR auditing capabilities to meet this type of changing prescribing pattern. In addition, the PBM should have the capability to audit prescribers for questionable prescribing patterns.

#8: Validating Narcotics Use through Reporting

If a DUR program is successful, there will be a reduction in unnecessary medication usage, including narcotic use. A PBM should easily be able to validate those reductions through a wide range of real-time and ad-hoc reports.



User-run reports: The PBM should offer a tool that gives a client an option to run a wide range of reports to gain an in-depth understanding of all activity. To maximize the effectiveness and ease of use of the reports, the PBM should ensure the reports are categorized into varying levels depending on how the reports will be used. For example, while all user levels will be able to access savings data, the claims professional should be able to access detailed claims information to help maximize savings opportunities such as individual reports that identify home delivery conversion opportunities, details on narcotics use and details on each injured worker.



Management level users should be able to run reports to assist with managing the claims professional, such as a report providing exception or override information as well as a report providing details on actions sent to the PBM.



Other available reports should include: savings reports that can be sorted by a range of time periods, jurisdictions, groups and/or branches, pharmacy network utilization and savings reports, generic efficiency and opportunity, as well as a wide range of trending reports including top prescribing physicians, top therapeutic classifications, top pharmacy medications, top ICD-9, top injury type and reports detailing prescribing physician habits.


Drug utilization review report:  To provide information on savings achieved as a result of the program, the PBM should have a detailed DUR report.  This report should provide information on savings achieved as a result of the program and should document savings in distinct areas rather than broad categories in order to provide the complete picture of DUR activity.(WCxKit)

Ad-hoc reporting: In addition to user-run reports and reports detailing DUR activity and savings, the PBM should have the ability to supply ad-hoc reports to assist with narcotic utilization management. If the PBM captures the data, then the PBM should be able to provide reports based on those data elements.




By partnering with a PBM, workers compensation payors can put an effective narcotics utilization strategy into place. A relationship with a strong PBM partner experienced in workers compensation will enable the payor to not only monitor utilization but stop point-of-sale fulfillment of unnecessary narcotics.



Author Tron Emptage, who holds a BS in Pharmacy, is Chief Clinical & Compliance Officer with Progressive Medical. Mr. Emptage has overseen Pharmacy Services, Clinical Services, National Account Management served as Vice President of Strategic Initiatives and Executive Vice President of Business. His 20-year plus experience in pharmaceutical and managed care defines him as a key player in moving the company forward in the arena of national pharmaceutical managed care. Contact him: or 800.777.3574 or visit Progressive Medical.

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About Progressive Medical
Progressive Medical offers cost management services and programs to the workers compensation industry. By combining its clinical expertise with access to an expansive network of pharmacies, home health care services and medical equipment and supplies, the company enables its clients to manage costs while providing quality care to injured workers. Learn more at Progressive Medical or call 866.939.5365.

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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.


©2011 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact


Ten Medical Cost Containment Strategies To Reduce OVERALL Costs

There are many available techniques to control medical cost in workers compensation.
A search of the internet for Medical Cost Containment will provide a tremendous amount of information but each website is focused on the product(s) or service(s) provided by the particular company. There are many and varied means of controlling medical cost in workers compensation which span a broader range of services than almost any single company can provide.
To be truly effective in controlling the medical cost of workers compensation, employers and insurers should not limit their medical cost containment efforts to only one or a few areas. While state statutes may limit or bar the use of some the methods of controlling cost, the employer or the insurer should utilize as many medical cost containment strategies as possible. All of the following medical cost containment strategies have been shown to save money for the employer or the insurer. (WCxKit)  Spend now to achieve overall lower workers compensation costs. This is how to hold costs down over the long term. This is referred to as the TLC (total loss costs).
Top 10 Medical Cost Containment Strategies
1.  A SUPERIOR Medical Provider Network is a group of doctors, hospitals and other medical providers with whom an insurer or a self-insured employer has prearranged for medical treatment for employees injured on the job AND provides better results than other providers – lower litigation rates, better medical outcome, faster return to work. 
2. Nurse Triage  is used as the very first phone call that is made (after the supervisor). The employee calls an RN who discusses the severity of the injury and the probably type of treatment that will be needed. These aren’t just any nurse, but specially trained ones using medical algorithms and overseen by sophisticated protocol to ensure appropriate referrals are made the the Emergency Dept, clinical treatment or self-care. If every injury is called in to Nurse Triage, the number of lost time claims will be reduced by 40%. The ROI is huge! I’ve toured the Medcor operation and was amazed at the efficiency and the training (I sat in the training room to view the type of training the RNs receive.) I was a guest of Broadspire who uses Medcor for their sophisticated medical protocol partner.  
3. Medical Management is the practice of having an experienced nurse case manager to coordinate and managed the medical care received by the employee. This includes both the senior nurse reviewer who may be dedicated to an account handling all lost time or serious medical claims for that company. They review all care and treatment for injured employees to insure it is appropriate and timely. If additional tests are needed they will advise the doctors. Their priority is getting the employee back to full recover.
4. Utilization Review is the independent confirmation of the need for a medical service. Utilization review includes precertification reviews before the medical care is provided, concurrent reviews while the employee is in the hospital or during on-going medical care, and retrospective reviews to verify the needs for the medical services already provided.
5. Medical Bill Reviews are normally done by companies that specialize in reviewing the medical bill to verify the accuracy of the medical bill diagnostic codes and medical bill charges. The medical bill charges are either compared to the state fee bill schedule or with what are reasonable and customary charges for the medical services provided. Medical bill reviews include both the audits of doctor bill and hospital bill auditing.
6. Pharmacy Benefit Managers are companies that specialize in managing and controlling the cost of medications prescribed for the employee. This includes both obtaining discounts on medications plus providing drug utilization reviews to prevent the excessive use of narcotics and other medications. Using physicians to actively review claims results in proactive pharmacy benefits management, rather than after the fact review of medications already taken, can stop overuse before it occurs.
7. Independent Medical Examinations occur when the employee is sent to another medical provider for a second opinion. Independent medical examinations are most often used when the employee’s medical recovery progress is slower than normal.
8.  Peer Reviews is the practice of sending the medical reports and diagnostic reports to another medical provider for a review of the medical information for the purpose of confirming the appropriateness and quality of the medical care being provided. Using physician review is in my opinion one of the most useful tools an employer can use. They can read he medical reports to find what’s NOT there. They look for other possible causes of injury, appropriateness of care and make sure employees go to the correct specialists.  This service may be called Peer-to-Peer.
9.  The era of computers has created the ability to use technology to obtain information that would not otherwise be available including:
1.      Predictive Modeling is used to identify early on those claims that have a high probability of becoming expensive claims so they can be acted upon quickly.
2.      Data Mining is used to identify high cost medical providers; medical providers who are slow to return the employee to work and to identify other claim related information that impacts claim cost.
3.      Benchmarking is using the known information about your workers’ compensation claims to compare your cost control results against others employers or insurers. (WCxKit)
10. Send me your ideas for YOUR favorite Medical Cost Containment Strategy. Let me know if it’s OK to share your ideas. Please write up to 200 words.

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.  Contact:

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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact

Utilization Review An Adjusters BEST Cost Control Weapon

A utilization review allows the adjuster to know if the medical care being provided to the employee is medically necessary and appropriate for the treatment of the injury or occupational disease and is one of the best weapons an adjuster can use to control workers’ comp costs.  
The  unintentional consequence of workers’ comp paying 100% of all medical expenses is, unfortunately, the employee is unconcerned about the cost of medical care he received. To be fair,  the employee normally does not know the medical ramifications of the treatment provided.   Both the employee (and often the adjuster) do not know if prescribed medical treatment  is repetitive of  care already provided, is not appropriate, or inadequate for the injury.
Utilization reviews vary in usage by different work comp insurers. Some insurance companies require a review of all planned treatments. Others require a utilization review only for specific types of medical care such as hospital admissions, inpatient surgery, ambulatory procedures, skilled nursing and rehabilitation services, planned prescriptions, and durable medical equipment.  
In most companies, the utilization review is conducted by a registered nurse (RN), who determines if the treatment is medically necessary. If the RN believes the medical treatment should be denied, or is unsure if the medical treatment is necessary, a physician conducts a second review of the information before approving or denying care.
Either the utilization review is in-house by the insurer or third party administrator, or done by an outside organization specializing in utilization review services. Ideally utilization reviews should always be completed within 7 days and preferably within 3 days. In some situations an expedited review may be needed;  for instance when the physician wants to immediately admit an employee to a hospital for further care.
Utilization review includes pre-certification reviews (also referred to as utilization management or prospective review), concurrent review, retrospective review, and re-review (also referred to as an appeal). The purpose of each type of review is to control the cost of the medical treatment without interfering in the employee's medical recovery. After each type of utilization review, all parties are notified of the review decisions.
Pre-certification Review
When first hearing the term “utilization review” most people think of what is actually the “pre-certification review.”  In a pre-certification review, before medical care is provided, the RN collects  all the necessary information including symptoms, diagnosis, test results, and the reasons the physician is requesting the medical service. The RN compares the information provided against the normal criteria for treating a specific type of injury or occupational disease.
If the medical service is necessary, it is approved. If the medical service is not necessary, then a physician at the utilization service reviews the medical information again to verify the denial of the service is correct.
Concurrent Review
Concurrent reviews occur during the time the medical treatment or service is being provided. The employee either can be an inpatient in a hospital or have on-going outpatient care. The RN approaches the concurrent review in the same way as the pre-certification review.
This type of utilization review is often overlooked by the workers’ comp adjuster, especially for outpatient care. The concurrent review verifies the medical necessity of the treatments and/or services provided to the employee and verifies the employee is receiving the right, most cost effective care. The workers’ comp adjuster who consistently utilizes the concurrent review of outpatient treatment shortens the time the work comp claims are open.
When the concurrent review is for inpatient care, it can shorten the hospital stay be limiting it to the amount of time the employee needs to be hospitalized. It can also be very helpful in identifying the medical care needed when the employee is discharged from the hospital. 
Retrospective Review
The retrospective review is used for either inpatient or outpatient services. A retrospective review, as the name implies, occurs after the medical services are provided. The procedure for the retrospective review by the RN as the other reviews. 
While physicians and hospitals recognize the need for  pre-certification reviews and concurrent reviews and accept them, they are less accepting of the retrospective review, especially if the medical care or medical service is denied. When a retrospective review denies a service the physician or hospital provided, they do not get paid, as they cannot bill the employee. [They often will request a re-review].
When a medical service is denied by a pre-certification review, a concurrent review, or a retrospective review, the employee or the medical provider can appeal the denial. When a re-review is requested, the physician at the utilization review service goes over all available medical information to determine if the denial should be reversed. Often the physician will bring in a second physician specializing in the type of medical care needed. The specialist will confirm the denial or reverse it. (workersxzcompxzkit)
Utilization review is a win-win process for all involved. The self-insured employer or the workers’  comp insurance company can eliminate the cost of unnecessary medical services through the utilization review process. The physician and employee benefit by not wasting time on medical care that does not expedite the employee's recovery. 
  \Author Robert Elliott, executive vice president, Amaxx Risks Solutions, Inc. has worked successfully for 20 years with many industries to reduce Workers’ Compensation costs, including airlines, healthcare, manufacturing, printing/publishing, pharmaceuticals, retail, hospitality and manufacturing. Contact:   or 860-553-6604.

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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.

©2010 Amaxx Risk Solutions, Inc. All rights reserved under International Copyright Law. If you would like permission to reprint this material, contact


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