Processing a med-auth/UR request is largely a manual process that is complicated, time-consuming and expensive. It is also a highly regulated process that can result is serious fines and penalties if a payer fails to comply with various regulations and procedures. However, the potential of UR to eliminate unnecessary medical expense from the worker's comp system is significant and it continues as a substantial cost containment strategy today.
Most medical requests come into the claim office and are subsequently triaged to be either approved or escalated to a professional UR review. Typically, the triage is conducted by either a claims professional or a nurse. The accuracy of the triage to UR is a key factor in determining the ROI on UR. Simply stated, a request that is submitted to a high-level UR review that is certified, and therefore not modified or denied, is a non-productive investment by the payer.
Once the requests are determined to be valid requests, the question of medical necessity must be addressed. Should the request be approved or escalated to UR? Depending on the organization of the payer, these determinations will be made by either a claims professional or a nurse manager.
How Significant is the Issue?
To address the ROI issue, we reviewed 128,551 requests where the medical necessity triage escalated the request for a formal UR review. Our goal was to identify the percent of requests being submitted to UR were non-productive. The outcome of our study showed the claims teams made incorrect triage decisions 53% of the time, while nurses made incorrect decisions 45% of the time. The chart below illustrates the outcomes.
There's an old marketing adage that says, "Half my marketing investment is wasted, if I only knew which half." It appears that adage applies to Utilization Review as well.
Given the state of today's current triage methodologies, roughly half of the requests submitted for an expensive high-level UR review end up being a non-productive investment by the payer; resulting in an unnecessary expense and delay in an appropriate medical treatment. While the savings outcomes from the other half reportedly justify the waste created by the non-productive reviews, there is significant room for improvement in the current methodology of triaging medical requests for UR.
What Is EHS Doing To Correct This Situation?
EHS identified this issue in 2019 and committed to create a more effective process. In Q3/Q4 of 2020, we anticipate the release of a new ai-supported predictive model designed to triage medical requests with a much higher degree of accuracy than the current methodologies can deliver.