DataCare UR++SM reduces utilization review program costs by enabling claims adjusters and trained administrators to routinely approve 80% or more of all treatment requests and by significantly reducing the number of referrals to more expensive nurse or physician reviews. Quick approvals also shorten the time it takes for employees to return to work.

With the UR++:

  • Clients use their own business rules as the basis for configuring the system and can take into account evidence-based guidelines and state-specific mandates.
  • Using predictive modeling methodology, we help locate the critical information needed from medical reports to prioritize and route the referral to facilitate initial processing of requests.
  • Client-defined workflows then route treatment requests to appropriate personnel and non-medical personnel can handle 80% or more of request.
  • Non-medical personnel views request for authorization and medical reports with all the information they need for a quick and thoughtful decision. This includes a summary of all past requests and past-paid treatments. Claims examiners and administrative staff select treatment options from a menu written in plain English.  They do not need to understand medical codes or complex treatment guidelines, or answer complex medical questions.
  • Claims examiners or administrative staff can immediately escalate a file for nurse or physician review, based on treatment history or any other issue within the application. This takes away inefficiency and time spent in generating referrals to the nurse or physician reviewers.
  • If the treatment is approved, the system automatically sends authorization notification letters and faxes to injured workers and providers.

Paulo Franca Ph.D., DataCare’s President and Chief Technology Officer, commented, “Our customers have told us that systems claiming to provide “automated approval” end up approving too many expensive treatments which should have gone to physician review. Our system balances a decision support system with human judgment on complex treatment needs of workers comp claims.”

DataCare’s new UR++ offering can support multiple business rule sets, depending on the type of claim, and works well for organizations operating in multiple locations.