Utilization Review: Making It Work for the Workers’ Compensation Industry

Posted on 01.30.15

Utilization Review may not be physicians’ favorite aspect of patient care for good reason: it takes up staff time and office resources, and it could delay care and impact payment.

Five important UR-related questions raised by physicians at last summer’s Harbor Medical Director Meeting are:

  • Are the savings to the insurance company significant enough to justify the inconvenience both to the doctor and the patient and justify the cost of this process?
  • When a request is submitted for UR and it is denied, what is the doctor supposed to tell the patient? Should the doctor continue with the same treatment or stop treatment altogether?
  • Why all the emphasis on evidence-based medicine anyway? What about the “art” of medicine?
  • Why is it necessary to keep faxing the same report which has been submitted? Isn’t this available in the file?
  • Why is there such an issue today with the physician dispensing medication? Isn’t it easier for the patient to get this directly from the physician?

From this discussion it was clear that physicians are frustrated with the UR process, particularly in the face of request denials.

Below are suggestions on how to make UR work more effectively within the doctor’s office and workers’ compensation industry:


  • Physicians can provide better, consistent documentation for authorization on treatments. Often, the documentation is done by an office attendant/assistant versus the actual physician, which can cause a significant leakage in details. A lack of detail often leads to a denial, as the reviewer is not aware why a physician is ordering a test or procedure.
  • Include reasons why doctors are asking for certain treatments. Often, physicians do not specify why they want a test or procedure, or why they believe it to be necessary. What about this particular patient justifies the treatment being requested? If physicians include this information, it helps reviewers make the right decision.
  • More physician coaching sessions will make physicians aware of guidelines they may not know exist.
  • Have a designated person in the medical office trained to handle RFAs (Requests for Authorization). They will be familiar with what’s being filled out, not filled out, and what details are necessary to help reviewers perform their job properly. This expert could make sure the doctor is providing a good reason for the treatments/procedures being requested and can help push the claim more efficiently through the continuum of care.


How do you feel about utilization review in the workers’ compensation industry? How do you feel the process can be improved? Let us know by leaving a comment below.

Did you attend our Medical Director Meeting last year? Check out our video series under our “Learning Center” section, capturing highlights from attendees and presenters:


To learn more about how Harbor Health Systems can help lower claims costs for your organization, contact us today at (949) 273-7020.

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For more information, please contact info@harborsys.com