Utilization Review Management

The Workers’ Compensation Claim Tracker™ (WCCT) by Cognition includes a comprehensive system for managing Utilization Reviews, including screens for prompting data entry, automatic generation of required form letters in approved formats, easy handling of appeals and secondary reviews, management of billing and invoicing, and preparing the required data for UR Audits. UR management is both labor and data intensive. Customers want rapid response to their requests. WCCT replaces work processes that rely on paper intensive solutions with a multi-user, easy to access database. When one associate is out or busy, another employee can easily access records and respond to inquiries.

Effective July 1, 1993, all workers compensation insurers in Massachusetts are required to undertake utilization reviews of injured workers requests for health care services. The Utilization Review and Quality Assessment Program, 452 CMR 6.00 applies to all claims, regardless of the date of injury, for health care services rendered on or after October 1, 1993. The UR process assures that medical care and treatment is medically necessary, appropriate, and is being maintained.

The UR process is straight forward, but data intensive. A provider requests approval for a procedure for a patient under Workman’s Compensation. The request is then reviewed by an approved Utilization Review Agent. The Agent determines whether the requested procedure is warranted under the conditions, based on the existing UR guidelines. The Agent approves or denies the request and documents the guidelines used in the decision. The provider and/or patient then have an opportunity to appear any denial. The appeal request is then reviewed by additional experts and a final determination is made.

At each step of the process, the UR Agent is required to send specific letters including specific information in approved formats to the provider and the patient with regard to the status of the request, any approval or denial, and any actions taken if an appeal is lodged. In most cases, the turn around time for a request is less than two days.

Finally, as part of the process, the state requires audit reports from the UR Agent with regard to the actions that it took on providers/patients.

UR Management Highlights

Concept Of Operation

Managing Utilization Reviews requires daily attention by case managers. WCCT organizes data based on the individual claim and the organization. Multiple claims for a single individual are associated with the individual in the database. To facilitate data entry, WCCT stores a variety of lists, offering only the allowed choices for the fields. WCCT stores collections of employers, doctors, facilities, hospitals, contacts, locations, and other useful data that further simplifies data entry. In general, data used by various case managers is entered once and is then available to all case managers.

Utilization Review and Documents

Utilization Review (UR) requests are entered on claims opened for individuals. The UR input form includes the information specific to UR requests. In addition, any documents associated with the UR request are stored in the WCCT database. This includes any type of digital file, whether an original word processing document or a scan of a document. With the documents stored digitally in the WCCT database, any authorized system user can access these documents without having to search for the original.

Billing Information

When entering any action, the case manager simultaneous enters the billing information for the action. This tight link between case management actions and billing both automates the billing process and allows each case manager to track weekly production. Billing accuracy increases and billing omissions decline. For certain actions, automatic billing takes places, further increasing billing actions and reduction of billing omissions.

Form Letter Generation

At each set of the Utilization Review process, communication is required between the UR Agent and the provider and patient. These form letters include:
Utilization Review Introduction Letter
Utilization Review Approval Determination
Utilization Review Adverse Determination
Utilization Review Denied Claim
Utilization Review Appeal Outcome/Approval
Utilization Review Appeal Outcome/AD Upheld
Utilization Review Compensability Unclear
Utilization Review Withdrawal of Appeal
Request for Additional Information

These form letters are automatically generated by the WCCT system, including the appropriate data coming from the database.

Report Generation

With all of the UR information stored in WCCT, reports are generated directly from the database. These reports include detailed claim reports, detailed UR reports, case management invoices by company, UR invoices by company, and similar reports for each claim. Data for OSHA 300 reports is output in the proper forms. Individual case managers can also review their specific billings/production by day, week, or month. End of month reporting and invoicing is generated automatically.

UR Audit Information Generation

The state requires periodic audits of the performance of the UR Agent. The WCCT automatically generates the output required for these audits from the data already in WCCT, improving accuracy and reducing the time required to generate the reports by the Agent.

Data Access

The UR data is organized so that the necessary reports are either generated automatically or by simple queries. WCCT includes powerful graphical data navigation tools, further easing data access.

WCCT is a Cognition Corporation Knowledge Center® (KC) application. WCCT is easily deployed across a geographically dispersed environment including one or more data servers, multiple clients, and terminal server access. Web based browser access is also supported. Satellite offices become part of the home office.