WCLA MCLE 11 -2 -11 Utilization Review

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WCLA MCLE 11 -2 -11 • Utilization Review: The New Provisions & Practical Pointers • Wednesday November 2, 2011 • 12: 00 noon to 1: 00 pm • James R. Thompson Center Auditorium, Chicago, IL • 1. 0 Hour General MCLE Credit

Utilization Review Applicability & Medical Treatment Guidelines • • Added to Section 8. 7, the Utilization Review section Applicability: “The changes to this Section made by this amendatory Act of the 97 th General Assembly apply only to health care services provided or proposed to be provided on or after September 1, 2011. ” Do already litigated prospective medical cases involve services to be provided? Section 8. 7(a) amended in the following way: “The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care of or nationally recognized peer review guidelines as well as nationally recognized treatment guidelines and evidence-based medicine evidence based upon standards as provided in this Act. ” No change from current law? (correction of typo really) Nationally recognized treatment guidelines and evidence based medicine: Medical treatment guidelines: substantive as to what kind of treatment; eg. ACOEM , ODG, AAOS Utilization Review Standards: procedural as to how to do UR; eg. URAC

Utilization Review Medical Treatment Guidelines • IL does NOT ADOPT by law or by rule ANY ONE PARTICULAR set of medical treatment guidelines; no one set is correct, presumptively or otherwise • There are MANY sets of medical treatment guidelines • National Guideline Clearinghouse: www. guideline. gov (2700? ); EG: American Academy of Neurology has 58, “Symptomatic Treatment For Muscle Cramps” • Some are better than others; Institute of Medicine of the National Academies, “Clinical Practice Guidelines We can Trust; ” March 2011, www. iom. edu • Evidence-based medicine: levels of evidence for primary research question; I-V, from most to least rigorous • Where does your medical treatment guideline fall?

Utilization Review URAC • Utilization management standards (procedural: how is UR done) • www. urac. org “URAC, an independent, nonprofit organization … accreditation, education and measurement programs. ” • Where do I get the URAC standards? : http: //insurance. illinois. gov/URO/Workers. Comp. UMStdsv 50. pdf • Standard WCUM 14: Peer review must be conducted by person who holds valid license in “same licensure category” as the ordering provider (Pg. 70) • Standard WCUM 17: Review determination must be made within 72 hours for urgent care, 15 days for non-urgent care (Pg. 72) • Definition: “Case involving Urgent Care”: 1) serious jeopardy to life or health or regaining of maximum function ; or 2) severe pain in the opinion of the physician with knowledge (Page 21)

Utilization Review Section 8. 7, added to subsec. (i) • • • (i) Upon receipt of written notice that the employer or the employer's agent or insurer wishes to invoke the utilization review process, the provider of medical, surgical, or hospital services shall submit to the utilization review, following accredited procedural guidelines. (1) The provider shall make reasonable efforts to provide timely and complete reports of clinical information needed to support a request for treatment. If the provider fails to make such reasonable efforts, the charges for the treatment or service may not be compensable nor collectible by the provider or claimant from the employer, the employer's agent, or the employee. The reporting obligations of providers shall not be unreasonable or unduly burdensome. (2) Written notice of utilization review decisions, including the clinical rationale for certification or noncertification and references to applicable standards of care or evidence-based medical guidelines, shall be furnished to the provider and employee. (3) An employer may only deny payment of or refuse to authorize payment of medical services rendered or proposed to be rendered on the grounds that the extent and scope of medical treatment is excessive and unnecessary in compliance with an accredited utilization review program under this Section. (4) When a payment for medical services has been denied or not authorized by an employer or when authorization for medical services is denied pursuant to utilization review, the employee has the burden of proof to show by a preponderance of the evidence that a variance from the standards of care used by the person or entity performing the utilization review pursuant to subsection (a) is reasonably required to cure or relieve the effects of his or her injury.

Utilization Review Provider Obligation & Payment • Added to Section 8. 7: (i) Upon receipt of written notice that the employer or the employer's agent or insurer wishes to invoke the utilization review process, the provider of medical, surgical, or hospital services shall submit to the utilization review, following accredited procedural guidelines. • (1) The provider shall make reasonable efforts to provide timely and complete reports of clinical information needed to support a request for treatment. If the provider fails to make such reasonable efforts, the charges for the treatment or service may not be compensable nor collectible by the provider or claimant from the employer, the employer's agent, or the employee. The reporting obligations of providers shall not be unreasonable or unduly burdensome. • Is “no payment” penalty mandatory? “may not be compensable nor collectible” • Who decides if “the provider fails to make such reasonable efforts”? IWCC makes this decision • What is reasonable, unduly burdensome? Look to URAC procedural guidelines; expert testimony about URAC (EG, PEER TO PEER)

Utilization Review Required in Necessity Dispute? • 8. 7(i) “(2) Written notice of utilization review decisions, including the clinical rationale for certification or non-certification and references to applicable standards of care or evidence-based medical guidelines, shall be furnished to the provider and employee. ” • Impact: Already required by URAC, WCUM 22 (pg. 74) • 8. 7(i) “(3) An employer may only deny payment of or refuse to authorize payment of medical services rendered or proposed to be rendered on the grounds that the extent and scope of medical treatment is excessive and unnecessary in compliance with an accredited utilization review program under this Section. ” • Impact: Necessity must be disputed with UR; IME alone insufficient to dispute necessity; careful practitioners will be wary of waiver of necessity defense; be careful of penalties for unreasonable (by law) defense (necessity dispute without UR)

Utilization Review Burden of Proof • 8. 7(i): “(4) When a payment for medical services has been denied or not authorized by an employer or when authorization for medical services is denied pursuant to utilization review, the employee has the burden of proof to show by a preponderance of the evidence that a variance from the standards of care used by the person or entity performing the utilization review pursuant to subsection (a) is reasonably required to cure or relieve the effects of his or her injury. ” • Impact: “When”: always; UR is required to dispute necessity • Impact: “Burden of proof”: No change; EMPLOYEE HAS ALWAYS HAD BURDEN OF PROOF OF NECESSITY • Impact: “Variance from standards of care”: No change; EG: Treatment plan different from ACOEM (18 rather than 12 PT’s); Yes, why would Petitioner try case if agrees with ACOEM • Impact: “Reasonably required…”: No change; straight out of 8(a)

Utilization Review Depositions • • • 8. 7(i) “(5) The medical professional responsible for review in the final stage of utilization review or appeal must be available in this State for interview or deposition; or must be available for deposition by telephone, video conference, or other remote electronic means. A medical professional who works or resides in this State or outside of this State may comply with this requirement by making himself or herself available for an interview or deposition in person or by making himself or herself available by telephone, video conference, or other remote electronic means. The remote interview or deposition shall be conducted in a fair, open, and cost-effective manner. The expense of interview and the deposition method shall be paid by the employer. The deponent shall be in the presence of the officer administering the oath and recording the deposition, unless otherwise agreed by the parties. Any exhibits or other demonstrative evidence to be presented to the deponent by any party at the deposition shall be provided to the officer administering the oath and all other parties within a reasonable period of time prior to the deposition. Nothing shall prohibit any party from being with the deponent during the deposition, at that party's expense; provided, however, that a party attending a deposition shall give written notice of that party's intention to appear at the deposition to all other parties within a reasonable time prior to the deposition. ” Impact: A lot more depositions of UR experts; a lot more litigation over dedimus to take UR expert’s deposition Impact : Interaction with Rule 7030. 60 & Section 16?

Utilization Review Consideration & Weight • • • 8. 7 (i): An admissible A utilization review shall will be considered by the Commission, along with all other evidence and in the same manner as all other evidence, and must be addressed along with all other evidence in the determination of the reasonableness and necessity of the medical bills or treatment. Nothing in this Section shall be construed to diminish the rights of employees to reasonable and necessary medical treatment or employee choice of health care provider under Section 8(a) or the rights of employers to medical examinations under Section 12. Impact: “An admissible”; Confirms that UR’s not generally admissible or automatically admissible, supported by deposition provision Impact: “Shall”; No reason to believe that admitted evidence was not being considered previously; does not change weight of UR; still NO presumption or determinant or conclusive effect See Noemi Solis v. Hospitality Staffing, 11 IWCC 792: Commission affirms Arbitrator’s decision that NO GREATER WEIGHT given to UR See Executive Mailing Service v. IWCC, Rule 23, No. 1 -10 -1014 WC, 6 -27 -11: “clearly not special evidence entitled to greater weight” Impact: “Must be addressed”; all admitted evidence must be (always should be) addressed; careful practitioners will do so in proposed decisions

Utilization Review Case Summaries (Win A Few, Lose A Few) – Venable v. United Airlines, 08 W. C. 047340 • UR rejected since purported to impose California standards in Illinois – Chamorro v. Workforce Staffing, 09 I. W. C. C. 55 • UR unpersuasive since answered biased questions posited by employer and misconstrued basic facts of the case, i. e. , non-compliant with URAC guidelines – Salgado v. Cardone Record Service, 09 I. W. C. C. 171 • UR adopted to limit chiropractic care to 6 visits – Garcia v. Executive Mailing Service, 09 I. W. C. C. 0310 • UR was rejected since efficacy requirement too restrictive for the proposed treatment – discogram and intradiscal electrothermic therapy – Jackson v. City of Springfield, 09 I. W. C. C. 1124 • UR adopted to find that 3 to 5 of 68 chiropractic visits were medically necessary – Cantua v. United Airlines, 09 W. C. 041232 – Ramirez v. Gill Management, Inc. , 10 I. W. C. C. 0141 • UR adopted to find that only 10 chiropractic visits were medically necessary • UR adopted to deny discogram

Utilization Review Case Summaries – Masso v. Frontline Transportation, 10 I. W. C. C. 0314 • UR adopted to find six chiropractic visits reasonable; Commission rejected arbitrator’s concern that UR could deny necessary prospective medical care – Vadakin v. Subway, 10 I. W. C. C. 0414 • UR that did not include a written report was rejected – Keafer v. City of Kincaid , 10 I. W. C. C. 0707 • UR adopted to find prospective fusion medically unnecessary – Gomez v. Juno Mfg. , 10 I. W. C. C. 1256 • UR adopted to find 3 -5 weeks of a 10 month period of chiropractic care was medically necessary – Escatel v. Civil Contractors, 10 IWCC 1255 • UR adopted to find that medical providers billed for unreasonable and excessive care – Barlow v. Johnny’s Restaurant, 10 IWCC 1291 • UR results and objective testing established that elbow surgery was not medically necessary

Utilization Review Case Summaries – Noemi Solis v. Hospitality Staffing Solutions, 11 I. W. C. C. 792 • UR not persuasive because it ignores the complexity of the injuries – Rosales v. Robert W. Hendricksen Co. , 11 I. W. C. C. 776 • UR rejected given apparent confusion over location of symptoms – left vs. right – Carpenter v. State of Illinois, State Retirement System, 11 I. W. C. C. 798 • UR rejected since opined on causation – Coor v. Lagrou Distribution, 11 I. W. C. C. 0660 • UR adopted to support IME finding of MMI – Wilcox v. Professional Transportation, 11 I. W. C. C. 0544 • UR rejected since failed to consider full medical records

Utilization Review Case Summaries – Medrano v. Scholoss Co. , 11 I. W. C. C. 919 • UR adopted to determine final date for medically necessary care – Melvan, v. Holcim Cement, 11 I. W. C. C. 819 • UR rejected since conclusions mirrored employer’s unsuccessful 19(b) hearing arguments – Bonadonna v. Wings Program, Inc. , 11 I. W. C. C. 448 • UR rejected since UR doctor’s testimony revealed bias to limit treatment in conflict with the ODG – Hamilton v. David Renshaw D/B/A Dairy Queen, 11 I. W. C. C. 226 • UR unpersuasive since “internally inconsistent” and because the UR doctor not registered or certified to perform a UR – Lorena v. Elite Staffing, Inc. , 11 I. W. C. C. 0494 • UR rejected since failed to address significant medical evidence and reference guidelines – King v. RGIS Inventory Specialists, 11 I. W. C. C. 0579 • UR unpersuasive since based solely on one IME and did not consider the treatment records

Utilization Review Case Summaries – Pinnell v. State of Illinois, Department of Transportation, 11 I. W. C. C. 0218 • UR declined to certify massage therapy as well as use of prescription medications; employer not liable for treatments that URs (conducted by two board certified orthopedic surgeons) did not certify – Avila v. Elite Staffing, 11 I. W. C. C. 0217 • Treatment prescribed by doctor found medically necessary though contrary to UR findings; ordering physician’s opinion more credible given UR’s qualifications and the UR’s lack of response to the ordering physician’s opinion – Mejia v. Ron’s Staffing, 11 I. W. C. C. 0164 • UR certified only 6 of 107 chiropractic visits. Arbitrator found no credible medical basis to justify all the chiropractic treatments and PT relying on UR – Fernandez v. ADP Total Source/ H. R. Slater Co. , 11 I. W. C. C. 0164 • UR non-certification of recommended lumbar-fusion, citing the need for multiple issues to be addressed pre-operatively, ordering doctor failure to appeal, and opinion of IME physician resulted in denial of surgery

Utilization Review in Illinois November 2011

Overview Utilization Review - history State of Illinois requirements of URO URAC Standards Types of Review / URAC Process/Timeframes Guidelines – Evidence-based Medicine Arbitrator Feedback Review UR determinations closely Request Attorney Packet from UR Cor. Vel contact information © 2011 Cor. Vel Corporation.

Why was UR instituted? Abuses Overuse of testing Inappropriate testing for diagnosis Inappropriate hospital stays Lengthy hospital stays Medical studies – that physicians rely on – have always been around to help physicians – specialty organizations decide on treatment © 2011 Cor. Vel Corporation.

State of Illinois requires companies who perform UR UROs are required to follow the URAC standards “sufficient to achieve URAC accreditation” (820 ILCS 305/8/7) “Nothing in this Act shall be construed to require an employer or insurer or its subcontractors to become URAC accredited. ” (820 ILCS 305/87) Must register and apply for certification with the State of IL every 2 years. © 2011 Cor. Vel Corporation.

URAC and its Standards (WCUM) “Protector of the Utilization Process” Originally URAC was incorporated under the name Utilization Review Accreditation Commission” – the name was shortened to just the acronym “URAC” Accreditation serves as a symbol of excellence in the health care industry The standards apply to the utilization management process when it occurs in a workers’ compensation setting There are CORE Standards and WCUM standards - primary element has direct & significant impact on the welfare and safety of consumers/patients. The secondary element is desirable of a high quality program but does not have a direct impact on welfare and safety of consumers © 2011 Cor. Vel Corporation.

UR Process Initial Review The nurse receives the request for review and medical records If additional records are required, the nurse can contact the provider Nurse reviews the medical records and the treatment under review Applies to ODG guidelines Certifies if treatment is appropriate Informs the provider by phone of the certification Sends certification letters to provider, injured employee, attorney, adjuster If the treatment does not meet guidelines © 2011 Cor. Vel Corporation.

UR Process – when guidelines not met The UR nurse refers to Clinical Peer Reviewer Utilizing evidence based medicine and nationally recognized guidelines, the Clinical Peer Reviewer (medical doctor) reviews & provides a UR determination Based on Peer decision, the Certification or Non. Certification Letters are sent to all parties Appeal process and peer report are sent with all noncertifications © 2011 Cor. Vel Corporation.

Clinical Peer Reviewer Licensed doctor of medicine or doctor of osteopathic medicine or Licensed health professional in the same licensure category as the ordering provider or Health professional with the same clinical education as the ordering provider in clinical specialties where licensure is not issued © 2011 Cor. Vel Corporation.

Peer-to-Peer Conversations Clinical Peer must be available to discuss review determinations with the treating provider Requested by treating provider Purpose: allows treating provider a chance to discuss a UM determination before the initiation of the appeal process. (hopefully avoiding need formal and adversarial appeal process) © 2011 Cor. Vel Corporation.

Appeal process 30 days to Appeal UR Organization receives appeal request via fax or phone - can be made by treating provider, injured employee, attorney Sent to Clinical Peer Reviewer w/ any addl medical info Nurse sends out Cert or Non-Cert Ltr based on Peer determination 2 types of appeals: expedited and standard Right to standard appeal, if utilized expedited © 2011 Cor. Vel Corporation.

Clinical Peer Reviewer for Appeals Hold an active, unrestricted license to practice medicine or a health profession Must be Board-certified Are in the same profession and in a similar specialty as typically manages the medical condition Are neither the individual who made the original noncertification, nor the subordinate of such individual © 2011 Cor. Vel Corporation.

Administrative Non-Cert For lack of medical records UR calls provider requesting records Calls 2 nd day requesting same 3 rd day sends out Non-Cert for Lack of Medical Records Once records received – UR process continued © 2011 Cor. Vel Corporation.

Guidelines utilized by Nurses and Peer Physicians – Nationally Recognized ODG, ACOEM, Milliman-Roberts, Interqual Best practice, evidence-based medicine Evidence-based recommendations are based on valid scientific outcomes research, preferably research that has been published in peer reviewed scientific journals. Evidence-based information can be used to develop protocols, pathways, standards of care or clinical practice guidelines and related educational materials ODG updated regularly at 3 month, 6 month or yearly episodes © 2011 Cor. Vel Corporation.

Physicians utilize evidence-based medicine – what is evidence-based medicine? The practice of evidence-based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. Physicians arrive at medical decisions by relying on standards of care and individual clinical experience: v Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient v Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients © 2011 Cor. Vel Corporation.

Timeframes to Complete UR Review Per URAC: Cor. Vel Timeframes: PROSPECTIVE REVIEW: Initial review 72 for urgent care* 15 calendar days for Non-Urgent Care Prospective Review: 3 -5 days Concurrent Review: Initial review 24 hours for Urgent care* 15 calendar days for Non-Urgent Care Retrospective Review: Within 30 Calendar Days (May be Extended 15 days if Necessary) Appeal Timeframes: Expedited: completed with verbal notification within 72 hrs of the request, followed by written confirmation within 3 calendar days Standard: completed with written notification within 30 calendar days from receipt of request for appeal © 2011 Cor. Vel Corporation. Retrospective Review: Dependent on volume of records; number of treatments being reviewed – anywhere from 1530 days Appeals: Expedited: as per URAC Standard: within 30 days; rushed 10 days dependent on volume

Arbitrator Feedback - Comments Arbitrators comments: Litigator’s tool – just delays treatment Out-of-state Peers – not “local” medicine Credibility of Peer Physician – CVs are important Response to Arbitrators: If UR performed appropriately and within appropriate timeframes with cooperation of treating provider – it does not delay treatment Medicine is national / international – physicians rely on same medical standards; very competent physicians in all states Need to send appropriately to UR UR 4 p. t. visits – not appropriate Guidelines – “cookbook” medicine; developed by who? Occ med? Peer Physician – occ med – reviewing Specialist (Ortho) recommendations Guidelines were developed by physicians, specialists based on standards of care Peer physicians should be specialty to specialty – again appropriateness of reviewing company Disconnect between URO and Defense Attorneys require URO certification, CV of peer, peer report, non-cert letters, etc. Hearsay Peer reports are now sent to treating providers – helping to eliminate the complaint of hearsay © 2011 Cor. Vel Corporation.

Utilization Review is Beneficial Avoids unnecessary surgery v 2 nd or 3 rd or 4 th surgeries Promotes discussion between physicians on controversial treatment v. Patient is not a candidate v. Experimental v. Success rate Serves the patient if utilized appropriately © 2011 Cor. Vel Corporation.

Review the UR determination closely Is the non-cert due to poor documentation of the treating provider? Is the non-cert for a minimal amount of p. t. visits? Did the URO have the correct medicals in order to process UR? v MRIs are needed to review for appropriateness of surgery If there is a case manager on the case, ask the nurse to closely review the rationale for non-cert URO should have QA’d the peer report for accuracy © 2011 Cor. Vel Corporation.

Encourage your clients to: Refer to UR prospectively, concurrently Notify the provider in writing upon acceptance of the claim that utilization review is utilized on certain treatment Follow the process – allow appeals, peer-to-peer conversations © 2011 Cor. Vel Corporation.

Call Cor. Vel UR to Request an “Attorney Packet” Cor. Vel’s State of IL certification URAC Accreditation certificate UR non-certification letter Peer Report & Peer CV Appeal confirmation Appeal determination, Peer Report & Peer CV Reports on Peer-to-Peer conversations © 2011 Cor. Vel Corporation.

Cor. Vel UR – Contact and Referral Information Jenny Weber, RN, UR Supervisor Phone: 630 -874 -7357 e-mail: Jennifer_Weber@corvel. com Complete referral form – in packet E-mail: DG_UR@corvel. com Questions for referral: Kim Lindholm at 630 -874 -7362 © 2011 Cor. Vel Corporation.