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Question: How Does CompAlliance Define Successful Utilization Management and Utilization Review?

Answer: CompAlliance believes Utilization Management/Review is an effective tool utilized to assure the recovering worker receives the most appropriate treatment, with a goal of return to health and function. CompAlliance believes there is a difference between a proactive Utilization Management approach and a reactive Utilization Review approach when facilitating appropriate care. CompAlliance’s URAC accredited Utilization Management program has shown outstanding results and great satisfaction for our clients. Our philosophy of collaborating with providers reduces the overall claims cost by expediting the most appropriate treatment in order to speed recovery and Return to Work. Conversely, when a Utilization Review program is focused on denials, they often ADD to the cost of a claim by delaying recovery and adding friction to the claim. The CompAlliance Utilization Management Program views treatment as a continuum and examines whether the treatment plan is the most effective and appropriate to achieve resolution of the recovering worker's condition.

• CompAlliance Nurses and Physicians collaborate and negotiate with the treating physician to develop a treatment plan most appropriate for the injured worker, rather than evaluating a treatment request in a vacuum.
• When the CompAlliance nurse receives a treatment request for an injury that would indicate future treatment would be required, rather than evaluate only the initial treatment request, the nurse reaches out to the provider to discuss the treatment plan as a continuum. As a result, when future treatment requests are submitted from the provider, the additional treatment will have already been reviewed with our Nurse or Physician and agreed upon as appropriate; a timely approval can be provided, thereby expediting treatment.
• CompAlliance does not believe we need to deny care in order to show savings. We look at all details related to the case and understand timely treatment will yield better outcomes for the injured worker and employer in the long run.
• CompAlliance researches current regulation to ensure clients adhere to current regulatory requirements, changing trends, and to manage costs appropriately.
The CompAlliance collaborative approach fosters excellent relationships, expedites recovery and reduces overall costs.

Answered by: CompAlliance

Categories:  Workers Compensation  Injured Workers  Nurse Hotline    

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