Time after time, adjusting offices find themselves asking the same question: “Should we approve this request for physical therapy, or is it worth sending to UR? We usually just go ahead and approve these, but we have been seeing PT requests for this patient pop up an awful lot this past month… Let’s just approve this one.”

Sound familiar? Adjusters deal with similar situations on a day-to-day basis, but it is often hard to differentiate between what should be reviewed by a medical specialist and what can just be approved. Something as simple as a PT request may come in quite often, but what if it is already the 24th PT request this month on a relatively straightforward injury, such as Carpal Tunnel? Is further, more intensive treatment needed, such as a surgery? The PT may not be working to help solve the situation, but may be lengthening the recovery period for the patient, costing more and more every day for the payor.

Physical therapy is not the only request where questions like this are asked. They can come in all forms and every adjuster is familiar with just how creative requesting providers can be, but from this simple example it is clear to see that both patient treatment history and, if possible, medical guidelines need to be consulted at the adjuster level–either by the adjuster themselves or by another strategic staff member at the adjusting office. However, the adjuster/staff does not have time to manually consult guidelines and patient history for every request that comes across their desk, nor does it make financial sense to forward everything on to UR. A better median needs to exist!

Current software solutions on the market today should be able to integrate patient treatment history, medical guidelines, and even client-specific guidelines to provide the adjuster with the most reasonable recommended action: referral to formal UR, objecting for a non-medical reason, or sending out an approval letter. It is important to note that individual companies may see a great variance in the common types of requests that come through and what should be approved. For this reason, it is necessary to have a system that not only references medical guidelines, but also takes into consideration client-customized rules that can be easily changed and optimized, as the industry evolves and more data is gathered.

To feed adjusting-level authorizations back into the rules engine, as well as for overall compliance, it is extremely important that the system at hand tracks the request and marks the determination even after sent to formal UR.

DataCare’s new UR++ system fits the bill! As soon as request information is filled in, it is run instantaneously against the desired guidelines and client rules, rendering a recommendation in less than a second. Adjusters can review all rationales, including relevant billing history, before approving, referring, or objecting. After referring, all requests continue to be tracked, so the end result of all requests can easily be retrieved to ensure current client rules are as efficient as possible.

The end result is adjusters and staff spend 60-70 percent less time analyzing requests and are extremely confident in what they approve and send to UR knowing that it is backed by medical and company guidelines. UR only receives items that require medical expertise and that are not covered by medical or company guidelines. Rather than saddling adjusters or utilization reviewers with extra work to lessen the load on the other, both sides can be served by taking many of the most common requests out of the equation entirely; the Perfect Balance can exist!