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California Medical Bill Reviewer Certification

California Medical Bill Reviewer Certification. Unit 1: Workers’ Compensation Benefit Program Module 5: Utilization Review. Overview.

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California Medical Bill Reviewer Certification

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  1. California Medical Bill Reviewer Certification Unit 1: Workers’ Compensation Benefit Program Module 5: Utilization Review

  2. Overview Hi! In this module, you learn about utilization review and the different stages of review. Then, you will learn about the different levels within the review process. Let’s start by discussing the purpose of utilization review and how it is used in California... Part I: • The Purpose and Goals of Utilization Review • How Utilization Review was Implemented in California Part I: • The Purpose and Goals of Utilization Review • How Utilization Review was Implemented in California • Differentiate Between Stages of Utilization Review • Prospective Treatment • Concurrent Treatment • Retrospective Treatment

  3. What is Utilization Review? • Utilization Review (UR): a process that provides approval for medical services provided to the injured worker. Purpose of Utilization Review Utilization review is used in an effort to discourage the use of unnecessary or inappropriate medical services, without jeopardizing necessary high-quality care.

  4. What is Utilization Review? • Utilization review provides case by case assessments of the frequency, duration, level, and appropriateness of medical care. By determining if medical treatment was or is necessary, utilization review: • Manages costs of health care. • Improves patient care. • Improves decision making regarding necessary treatments.

  5. 1993: UR became part of the California workers’ compensation system in 1993. The State of California adopted legislation that required all insurers to comply with the new legislation. Utilization Review in California

  6. It is important to remember that UR does not guarantee payment or approve charges for specific services. Utilization Review in California • Recall that California law requires that employers pay for all medical care that is reasonably necessary to treat an injured worker. Utilization review processes facilitate this requirement by approving the services that are provided to an injured worker.

  7. Utilization Review Stages Now that you understand the basics of utilization review, let’s take a look at the different stages of review. Part I: • The Purpose and Goals of Utilization Review • How Utilization Review was Implemented in California • Differentiate Between Stages of Utilization Review • Prospective Treatment • Concurrent Treatment • Retrospective Treatment • Differentiate Between Stages of Utilization Review • Prospective Treatment • Concurrent Treatment • Retrospective Treatment

  8. Stages of Utilization Review • Utilization review can be divided into three stages of treatment: Concurrent Prospective Retrospective

  9. Prospective Treatment • Prospective Treatment: review and authorization before the treatment begins. Prospective Treatment • If the physician recommends a surgical procedure be performed, authorization from the insurance carrier is requested before the surgery occurs. • Authorization can also be required for diagnostic services such as MRI’s and CT scans, referrals to specialists, physical therapy, and certain durable medical equipment.

  10. Concurrent Treatment • Concurrent Treatment:review and authorization during treatment. Concurrent Treatment • Most commonly occurs when additional days of service, such as hospital inpatient days, are requested for the patient’s care. • Authorization can also be required when additional physical therapy or chiropractic sessions are needed.

  11. Retrospective Treatment • Retrospective Treatment: review after the procedure has occurred, but was not pre-authorized. Retrospective Treatment • This is a riskier practice for the provider, as the insurer may not feel the service was required and deny payment. • This is a riskier practice for the provider, as the insurer may not feel the service was required and deny payment.

  12. Levels of UR Now that you understand the basics of utilization review, let’s take a look at the different levels of review. Part II: • Understand the Different Levels of Utilization Review • Initial Reviews • Second Level Reviews • Third Level Reviews: Request for Expedited Hearing Part II: • Understand the Different Levels of Utilization Review • Initial Reviews • Second Level Reviews • Third Level Reviews: Request for Expedited Hearing

  13. Utilization Review: A Tiered Approach • There are three levels of utilization review. Third Level Reviews Second Level Reviews Initial Reviews

  14. Initial Reviews Initial Reviews • Initial reviews: reviews usually performed by registered nurses. “Hmm, why are so many tests requested?” Registered nurses may: • Authorize treatment. • Request additional documentation. • Pass the request on to second level review. The initial review commonly utilizes software based on national criteria that: • Links diagnoses to services performed. • Reviews all submitted documentation.

  15. Second Level Reviews Second Level Reviews • Second level reviews: reviews performed for more complex services or those services that have been denied per an initial review. “Surgery for a broken toe???” Per California regulation, second level reviews are performed by licensed physicians. • Only a licensed physician may delay, modify, or deny requests for authorization of medical treatment for reasons of medical necessity.

  16. Third Level Reviews Third Level Reviews • Third Level Reviews: reviews performed to resolve disputes or the lack of a timely response to a UR request. If a reply to a UR Request is not given within seven days, or there is a dispute concerning authorization, the injured worker or his representative may file a Request for Expedited Hearing. Denied! Approved! Approved!

  17. Requests for Expedited Hearing are submitted to the Workers’ Compensation Appeals Board. Only an M.D. not previously associated with the claim can oversee an appealed denial of authorization. Requests for Expedited Hearing

  18. Utilization review accomplishes the following: Goals of Utilization Review Allows the insurer an opportunity to evaluate the medical necessity of the services requested. Gives the provider the reassurance the services are approved & will be compensated. Provides the injured worker the necessary treatments to recover from injury and return to work.

  19. What Utilization Review is, and how it works. The difference between prospective, concurrent, and retrospective treatment reviews. The Tiered Approach: Initial, Second Level, and Third Level Reviews. How Utilization Review helps the insurance carrier, provider, and injured worker. Summary

  20. Module 5 Quiz Click on the link to go directly to the quiz. Feel free to review any of the material before you move on. Good Luck! Quiz: U1M5: Utilization Review

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