MEDICAL UTILIZATION REVIEW (“MUR”)

1. MEDICAL UTILIZATION REVIEW (“MUR”) Presented by: Nancy A. Fitzgerald, RN, BSN, JD 303-293-8800 nfitzgerald@mdmc-lawco.com

2. . . . what you always wanted to know about an MUR (really?) but were afraid to ask.

3. Part I: The Six W’s of MURs • #1: WHAT is an MUR? • #2: WHERE do you find MUR information? • #3: WHY would a “party” request an MUR? • #4: WHO are the key players in an MUR? • #5: WHEN is an MUR decided? • #6: WOW (or What does an MUR cost)?

4. #1: WHAT is an MUR? • An MUR is a statutory means within the Division of Workers’ Compensation by which a “party” can request that the care/service provided by an “authorized provider” be reviewed by a committee of three “peer professionals” to determine whether such care/service is reasonably necessary and/or reasonably appropriate according to accepted professional standards. • If the committee determines that the care/service is not reasonably necessary or appropriate by a majority or unanimous vote, the Director must order: • A change of provider (majority vote); and possibly • Retroactive reimbursement for services rendered from a particular date (unanimous vote); and possibly • Revocation of the provider’s accreditation (unanimous vote for injuries after 7/1/91). W.C.R.P 10; C.R.S. §8-43-501(1), -503(1).

5. #2: WHERE do you find MUR information? • The Act: • C.R.S. § 8-43-501: sets forth the “mechanism” in a narrative fashion (handout) • C.R.S. § 8-43-503: provides the purpose of an MUR (handout) • The Rules: • W.C.R.P. 10: provides step-by-step instructions to file a request for an MUR (handout) • Pertinent Case Law: • Rook v. ICAO, 111 P.3d 549, 552-53 (Colo. App. 2005) (a registered nurse, who may have been the insurer’s employee, may prepare the medical report required under C.R.S. § 8-43-501(2)(b)) • Secondary Sources: • Craig C. Eley, Medical Utilization Review Under Worker’s Compensation, 17 U. Colo. L. Rev. 1995 (1988): summary of SB 106, which established the MUR mechanism • WC Website: http://www.colorado.gov/cs/Satellite?c=Page&childpagename=CDLE-WorkComp%2FCDLELayout&cid=1251567882354&pagename=CDLEWrapper • http://www.coworkforce.com/dwc/PUBS/ur2002.pdf (Utilization Review Program pamphlet - handout) • Other Resources: • Nancy Fitzgerald: nfitzgerald@mdmc-lawco.com, (303) 293-8800 • Kristin Caruso: kristin.caruso@lewisbrisbois.com, (303) 861-7760

6. #3: WHY would a “party” request an MUR? • An insurer or self-insured employer generally requests an MUR because that party suspects, in its humble and unprofessional opinion, that the care/service by one or more current providers is no longer “reasonably necessary or reasonably appropriate according to accepted professional standards.” C.R.S. § 8-43-501(1) (2). • In other words, that party suspects its money is not being used “to cure and relieve an employee from the effects of an on-the-job injury.” C.R.S. § 8-43-501(1).

7. #3: WHY would a “party” request an MUR? (continued) • Claimant may initiate an MUR if a prior request to have a personal physician or chiropractor provide care was denied. C.R.S. § 8-43-501 (2)(c).

8. #4: WHO are the key players in an MUR? • The “Party” requesting the MUR • Insurer, Self-Insured Employer or Claimant. • The “Provider Under Review” (“PUR”) • Medical doctor, Chiropractor, Dentist, Psychologist, etc. • The “Licensed Medical Professional” retained to prepare the case report • The “Committee” appointed to opine whether the care/service is reasonably necessary or reasonably appropriate

9. #5: WHEN is an MUR decided? • Some time periods in the MUR process are specified, others are not. • For example, Committee Members are not given a deadline to complete their review. • Generally, from start (submission) to finish (Director’s Order), an MUR takes about five to six months, but the entire process can take six to twelve months. Appeal would likely add another six to twelve months. • See Sample Timeline (handout)

10. #6: WOW – What Does an MUR Cost? • MUR Fee $1,250 • Case Report: $5,000 to $8,000 • Package Preparation: $1,000 to $1,500 • Total (estimate) $7,250 to 10,750

11. A Typical MUR How to Prove Medical Care/Services is Unreasonable/Unnecessary

12. A Typical MUR – Trigger • Trigger: Multiple inquiries re: status and multiple IMEs re: the PUR’s care/services • Must prove that care was NOT reasonably necessary to cure and relieve the effects of the injury; or • NOT reasonably appropriate according to professional standards to cure and relieve the effects of the injury

13. A Typical MUR – The Information Package (One Copy) • Request Form (handout): Request for Utilization Review – 1 page form identifying the party requesting review and the authorized physician to be reviewed • Copies of all admissions and/or orders filed or entered in the case • List of full names and medical degrees of all providers, other treating providers, and all consultants, IME’s, referrals • Fee of $1,250 payable to the Division Rule 10-2

14. A Typical MUR – The Medical Records Package (Seven Copies) • Table of Contents • Case Report by a licensed medical professional – dated within 30-days of the submission • Records – in chronological order in the following identified sections • 1. Employer’s First Report of Injury and/or Worker’s Claim for Compensation Form • 2. All records from PUR • 3. All records from other treating physicians • 4. All records from referrals, consults, IMEs • 5. All test results • 6. All medical management reports • 7. All hospital/clinic records Rule 10-2

15. A Typical MUR – The Case Report • LIMITED to the following, pursuant to C.R.S. § 8-43-501(2)(b) • Name, discipline of care, and specialty of PUR; • Claimant’s standard demographic info (age, sex, marital status, etc.); • Claimant’s employer and occupation/job title, dates of work related injury/exposure(s); • Date of initial treatment by the PUR and a briefchronological history of treatment to present, and “any significant contributing factors which may have had an effect on the length of treatment”; and • A brief statement from the medical professional in support of utilization review.

16. Unreasonable/Unnecessary Medical Care/Service(Sample Case 1) • 1990: Claimant sustains a work-related back injury (repetitive bending, twisting, lifting as a kitchen/counter worker at a fast food restaurant) • 1990’s: Claimant’s addictive personality is noted and back pain is treated with steroid injections, some narcotics (Darvocet N100 and Vicodin at times), PT, acupuncture, massage, psychiatric counseling/treatment, and psychotherapy, but Claimant able to work full time as an assistant property manager • 2002: Initial evaluation by PUR; OxyContin prescribed and Vicodin restarted • 2002-2005: Narcotic use escalates and function decreases; PUR prescribes Actiq lollipops in 2004 and Claimant stops working that same year; narcotic side effects (depression, sleep disturbances, constipation/bowel obstructions) require additional treatment; opioid habituation diagnosed by PUR in 2005 and PUR weans Claimant to Percocet for pain control • 2005: Insurer IME: Claimant capable of working full time with restrictions • 2006: Claimant requests additional pain medication and PUR restarts OxyContin

17. Unreasonable/Unnecessary Medical Care/Service(Sample Case 1 - Continued) • 2007: Insurer requests status report from PUR, who acknowledges need to wean patient off all opioid medications • 2007: Insurer IME: Claimant should be evaluated for maintenance care and medications should be reduced • 2007-2010: Narcotic use re-escalates and DIME indicates too many medications and no improvement in two years despite multiple therapies • 2009: Pharmacy records document narcotic use

18. Unreasonable/Unnecessary Medical Care/Service(Sample Case 1 - Continued) • 2009 Narcotic Prescriptions 1/10/09 Oxycodone 15 mg #120 15 days 1/15/09 Hydrocodone/APAP 10/325 #120 30 days 2/8/09 Hydrocodone/APAP 10/325 #120 30 days 3/5/09 Actiq lozenges 0.8 mg #15 15 days 4/2/09 Hydrocodone/APAP 10/325 #120 30 days 4/3/09 Hydromorphone 4 mg #120 15 days 4/30/09 Hydromorphone 4 mg #120 15 days 4/30/09 Actiq lozenges 0.8 mg #15 15 days 5/28/09 Actiq lozenges 0.8 mg #45 23 days 5/28/09 Hydromorphone 4 mg #120 15 days 5/29/09 Actiq lozenges 0.8 mg #45 30 days 6/22/09 Actiq lozenges 0.8 mg #120 30 days 6/22/09 Opana ER 10 mg #120 30 days 6/22/09 Hydrocodone/APAP 10/325 #120 30 days 7/17/09 Hydrocodone/APAP 10/325 #120 30 days 7/20/09 Hydromorphone 8 mg #60 15 days 7/20/09 Actiq lozenges 0.8 mg #120 20 days 7/20/09 Opana ER 10 mg #120 30 days 8/18/09 Hydrocodone/APAP 10/325 #120 30 days 8/18/09 Fentenyl Transdermal 25 mcg/hr #15 30 days 8/18/09 Actiq lozenges 0.8 mg #15 15 days 9/23/09 Actiq lozenges 0.8 mg #30 30 days 9/23/09 Fentenyl Transdermal 50 mcg/hr #15 30 days 9/23/09 Hydrocodone/APAP 10/325 #120 30 days 10/19/09 OxyContin Ter 40 mg #60 30 days 10/19/09 Hydrocodone/APAP 10/325 #120 30 days 10/24/09 Actiq lozenges 0.8 mg #90 22 days 11/16/09 Actiq lozenges 0.8 mg #90 30 days 11/16/09 OxyContin Ter 40 mg #60 30 days 12/15/09 Actiq lozenges 0.8 mg #90 30 days 12/15/09 Hydrocodone/APAP 10/325 #120 30 days 12/15/09 OxyContin Ter 40 mg #60 30 days

19. Unreasonable/Unnecessary Medical Care/Service(Sample Case 1 - Continued) • March, 2010: Insurer Pharm. D. IME concludes opioid use should be tapered based on review of Claimant’s medical and pharmaceutical records • July, 2010: Insurer IME (record review) concludes recent increased Actiq dose not medically necessary and PT and sleep study not reasonably necessary • August, 2010: Insurer IME (record review) concludes PUR’s treatment inconsistent with the Colorado Workers’ Compensation Medical Treatment Guidelines, clinically inappropriate, and dangerous to the patient; recommended care be transferred to another provider, and narcotic use discontinued • October-December, 2010: Insurer IME (record review) concludes re-starting Claimant on narcotics is medically inappropriate • March, 2012: Insurer IME (record review): recommends weaning off all narcotics. • May, 2012: MUR submitted • Oct., 2012: Change of provider ordered.

20. Unreasonable/Unnecessary Medical Care/Service(Sample Case 2) • 1/03: PUR first sees Claimant for psychiatric therapy related to a work injury that occurred in 1998 • 2003-2012: PUR continues to see Claimant 2-4 times per month and prescribe multiple psychotropic medications, despite repeated documentation of little to no progress • 2003-2010: PUR provides “summary” notes rather than individual therapy notes. For example, PUR’s “therapy notes” for the entire month of July, 2006 (3 visits) state: “Summary – July 2006: improved physical condition . . . but complaints of fatigue and depression.” Despite these brief notes, the PUR prescribed and/or refilled multiple medications in July, 2006, including Wellbutrin, Lorazepam, Paxil, Cyclobenzaprine, Dantrolene, Oxycodone, and Avinza. • 1/12: Opiate-related liver problems noted • 5/12: Insurer psychiatric IME: PUR’s treatment, although possibly beneficial, “does not comply with Guidelines because it does not show evidence of progress or recent reassessment and there is no indication of the services provided, when the services were provided, or what medications are being prescribed.” IME recommended a neuropsych evaluation. • 6/12: PUR provides insurer with a list of diagnoses and a treatment plan; disagrees with recommendation for a neuropsych evaluation

21. Unreasonable/Unnecessary Medical Care/Service(Sample Case 2 - Continued) • 9/12: Insurer IME (record review): PUR’s record keeping has improved and PUR should not be changed if psychotherapy is warranted; continues to recommend a neuropsych evaluation • 10/12: Insurer IME: recommended neuropsych evaluation to have a “fresh set of eyes” evaluate care • 11/12: Insurer IME (record review): epidural steroid injections not medically indicated • 12/12: Insurer requests progress report from PUR, who continues to recommend individual psychotherapy while at the same time noting that Claimant’s condition continues to deteriorate • 2/13: Insurer IME (record review): agreed that a “fresh set of eyes” was warranted because Claimant not improving despite individual psychotherapy and multiple treatment modalities • 4/13: MUR submitted • 8/13: Change of provider ordered.

22. MUR Outcomes • Change of Provider Ordered and No Appeal • C.R.S. § 8-43-501(4): claimant and insurer/self insured employer must agree on a new provider within 7 days; if no agreement, Director selects three possible providers and requesting party selects new provider • No Change of Provider Ordered and No Appeal • PUR continues to provide care and insurer/self insured employer continue to document issues related to care • Appeal: File appeal form with the MUR coordinator within 45 days (if payment of fees retroactively denied, hearing request must be filed within 30 days) • Burden: clear and convincing evidence