Utilization review

utilization_review

Using evidence-based medical guidelines, WellComp’s utilization review process stops over-utilization and medically unnecessary treatment while ensuring that injured workers receive appropriate, cost effective medical services.


 

WellComp offers:

  • Quality review decisions using evidence-based review guidelines
  • Strong physician involvement in the review process
  • National experience
  • Timely decisions
  • Customized services

 

PRE-AUTHORIZATION/PRE-CERTIFICATION REVIEW

WellComp’s experienced utilization review nurses coordinate and review requests for treatment and obtain physician reviews on any treatment not meeting evidence-based state and national treatment guidelines.

Peer-to-peer conversations are offered to the requesting physician whenever there is a potential for a denial of all or part of the requested services. Our physicians will also consult with treating physicians and claim adjusters on detailed treatment plans and return-to-work options. This frequent and open communication avoids unnecessary delays in approvals and treatment.

Our review process takes into consideration the unique aspects of each case. All denials are thoroughly documented and cite the rationale and specific treatment guidelines used in the review process. This results in more defensible decisions. 

Appeals of some initial decisions are inevitable. Our appeals process allows the treating physician the opportunity to provide additional information or justification for the treatment. A second specialty-matched reviewer physician examines the additional information to ensure that the appropriate review decision is made. Should a claim result in a lawsuit, we provide physician support during the litigation process.

PHYSICIAN PEER REVIEW
WellComp offers a comprehensive peer review process to provide a thorough, expert assessment of medical necessity and causal relatedness for proposed treatments and to identify and halt unproductive or unrelated treatment. Our national panel of review physicians consists of both staff physicians and contract physicians in active practice and from numerous specialties and states. All review physicians are board-certified in their respective specialties.

WellComp adheres to the jurisdictional requirements that apply to services provided in various states, including issues of licensure and use of the appropriate review guidelines.

RESULTS
WellComp’s robust utilization review program ensures that injured workers receive care that is appropriate, cost-effective and medically necessary. In addition, the right treatment recommendations result in faster treatment, recovery and return-to-work, and more cost effective outcomes. Monthly savings reports document review results to quantify the value of our services.