Many doctors disagree with claims professionals about how best to navigate a longstanding but evolving process used to get injured workers well and back to work: utilization reviews.
Disagreements over the effectiveness of parts of the utilization review, which insurers say ensures they only cover medically necessary drugs and treatments, could slow treatment and keep workers off the job longer, experts say.
Utilization reviews, which have existed for decades, are more often mandated, and several states have implemented drug formularies and treatment schedules. The process requires a back-and-forth between doctors and claims managers, involving documentation and imaging in some cases, to monitor care such as drugs, tests, surgery and physical therapy.
Workers’ compensation insurance companies, third-party administrators and pharmacy benefits have grappled with implementing new utilization review processes in recent years. For example, California implemented its medical treatment utilization schedule in 2018, and New York this year introduced a program to electronically streamline utilization reviews among providers and claims adjusters.
Additionally, according to reports compiled by the National Council on Compensation Insurance, 15 states have in place closed drug formularies that require prior authorization. Many forms and prior authorization processes were introduced due to, among other things, the opioid crisis, rising medical costs and poor outcomes among injured workers.
However, doctors have long rejected such prior authorization measures.
According to a survey of 1,001 physicians conducted in December 2022 by the American Medical Association, 80% said prior authorizations of treatment have led to early treatment discontinuation, 31% said the criteria for prior authorization—many of which are in place because of state regulations or parameters set by individual insurers — are “rarely or never evidence-based,” and 64% said authorization requests have led to “ineffective” initial treatments.
“It’s very frustrating because when you’re an (occupational injury) doctor and you know you’re following the science, all of this is delaying getting the person better,” says Dr. Douglas Martin, medical director of the Center for Neurosciences, Orthopedics & Spine Occupational Medicine in Sioux City, Iowa, who sees about 55 workers working with patients a week.
Dr. Martin serves as a medical examiner for several entities, including the Nebraska Worker’s Compensation Court and is president of the American College of Occupational & Environmental Medicine, whose guidelines were used to help create the California drug and treatment formulary. He said there is a lot of frustration among doctors when it comes to getting approvals for sound and current evidence-based care.
Many delays occur when it comes to physical therapy requests and can cause injuries to worsen or have significantly delayed recovery, he said.
Industry experts say they understand the problems that can arise but argue that utilization reviews go a long way to ensure adequate care and return to work.
“We see evidence-based medicine as a tool to ensure that employees receive the right care at the right time, with the overall goal of getting the employee back to work to pre-injury status,” said Leah Sharp, Franklin, Tennessee-based senior vice president with GBCARE, a unit of Gallagher Bassett Services Inc. “We don’t necessarily see it as a barrier to the system; it’s the care that’s being delivered. We’re making sure the employees are getting the right care.”
Ben Roberts, Duluth, Georgia-based vice president of utilization reviews for Genex Services, an Enlyte LLC company, said access to information about patients is often the first problem to solve.
“Among the biggest challenges in slowing down the utilization review process is really the completeness of the information provided,” he said.
Clinical use review teams evaluate the medical necessity and reasonableness of treatments against evidence-based guidelines, and the guidelines often have very specific requirements about what must be present for approval, Roberts said.
“Delays come into play when insufficient information is provided,” he said.
Experts say educating doctors about the process is part of the solution.
Changes in documentation processes in states like California and New York can be a challenge for doctors, Sharp said.
“It’s a scenario where it’s a culture shift,” Sharp said. “If physicians take the time to learn the guidelines or understand how to apply them in practice, they will see much less frustration than they currently do.”
Technology is also part of the answer, says Silvia Sacalis, a licensed pharmacist in Tampa, Fla., and vice president of clinical services for Healthesystems LLC.
“Part of the delays are due to challenges with workflow design and the manual turnaround of information,” she said.
More automation could streamline the process of transferring information that is relevant and needed for utilization reviews, Sacalis said.