One of the relentless cost drivers that isn’t going away quietly in workers’ compensation is medical treatment. In 2004, when California passed LC 4600 stating that Utilization Review was a mandate in workers’ compensation, it meant physicians requesting authorization for medical treatment needed to submit documentation expressing their rationale for any treatment. It was the belief that there were unnecessary medical treatments, unnecessary cost related treatment, and that the injured worker was not always receiving quality care.
Thus, reviewing physicians (or nurses) took on the dynamic process of evaluating the medical requests from medical providers. These reviews were then and are now continuing to be performed according to standards mandated by the state, and/or to other evidence based criteria. This process may include a discussion with the medical provider requesting the information as well as a review of the medical records to determine the “reasonable medical necessity” of the requested service. This process is time consuming and labor intensive if done manually according to the original conventional method. It is also deadline driven by state mandate.
Now, a utilization review software named DecisionUR, has automated this process by creating an electronic processing system based on triage/review information that Dr. Lester Sacks copyrighted back in the 1990s. He did this “before UR was even around” he says. DecisionUR, as a system, was developed in 2005 and has evolved over the past 10 years.
Lester Sacks, MD PhD, is the Chief Medical Officer for Patriot Care Management, Inc. DecisionUR was purchased by Patriot National, Inc. in August of 2014. Dr. Sacks explains that “A qualified experienced reviewer can take most of the documentation and review it and make a realistic decision in 15 to 20 minutes.” Using nurse reviewers without an automated system, one may be able to do 12 to 15 cases a day, if not complicated, according to Dr. Sacks.