WCLA MCLE 11-2-11
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Utilization Review
• Added to Section 8.7, the Utilization Review section
• Applicability: “The changes to this Section made by this amendatory Act of the
97th 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/WorkersCompUMStdsv50.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)
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(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
• 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, unreasonable, unduly burdensome? Look to URAC procedural guidelines; expert testimony about URAC (EG, PEER TO PEER)

Utilization Review
• 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
• 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.1-10-1014WC, 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
– 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

November 2011

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
CorVel contact information
© 2011 CorVel Corporation.

Medicare
Medicaid
HMO plans
PPO Plans
Slowly states have begun to adopt this practice for workers’ compensation cases
© 2011 CorVel Corporation.

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 CorVel Corporation.

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 CorVel Corporation.

“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 CorVel Corporation.

© 2011 CorVel Corporation.

Prospective reviews (pre-certs)
Concurrent reviews (ongoing treatment)
Retrospective reviews (treatment has been rendered)
© 2011 CorVel Corporation.

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 CorVel Corporation.

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 CorVel Corporation.

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

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 for formal and adversarial appeal process)
© 2011 CorVel Corporation.

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 CorVel Corporation.

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 CorVel Corporation.

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 CorVel Corporation.

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 CorVel Corporation.

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:
 Without clinical expertise, practice risks becoming tyrannized by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient
 Without current best evidence, practice risks becoming rapidly out of date, to the detriment of patients
© 2011 CorVel Corporation.

CorVel Timeframes: Per URAC:
PROSPECTIVE REVIEW :
Initial review 72 for urgent care*
15 calendar days for Non-Urgent Care
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
Prospective Review: 3-5 days
Concurrent Review: 3-5 days
Retrospective Review :
Dependent on volume of records; number of treatments being reviewed – anywhere from 15-
30 days
Appeals :
Expedited: as per URAC
Standard: within 30 days; rushed 10 days dependent on volume
© 2011 CorVel Corporation.

Notified by Phone
Followed up with a letter of certification
Non-certification letters include the Appeals Process and Peer Report
© 2011 CorVel Corporation.

Arbitrators comments: Response to Arbitrators:
Litigator’s tool – just delays treatment
Out-of-state Peers – not “local” medicine
Credibility of Peer Physician – CVs are important
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
Disconnect between URO and Defense Attorneys
Hearsay
Guidelines were developed by physicians, specialists based on standards of care
Peer physicians should be specialty to specialty
– again appropriateness of reviewing company
Attorneys require URO certification, CV of peer, peer report, non-cert letters, etc .
Peer reports are now sent to treating providers – helping to eliminate the complaint of hearsay
© 2011 CorVel Corporation.

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

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?
 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 CorVel Corporation.

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 CorVel Corporation.

CorVel’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 CorVel Corporation.

Phone: 630-874-7357 e-mail: Jennifer_Weber@corvel.com
E-mail: DG_UR@corvel.com
Questions for referral: Kim Lindholm at
630-874-7362
© 2011 CorVel Corporation.

© 2011 CorVel Corporation.