OVERVIEW

Utilization Review in Workers’ Compensation is organized by American College of Occupational and Environmental Medicine (ACOEM).

Release Date: 10/01/2021
Expiration Date: 09/30/2024

Description:
Utilization review (UR) is a process that assesses aspects of a treating provider’s care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc., concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers’ compensation (WC) system and is mandated in several states and jurisdictions. This 3-hour online training will discuss quality and value-based standards for UR and UR documentation, guidelines, regulatory issues and resources, documentation needs to support decisions, improve outcomes, and decrease conflicts. It will also review several case examples to apply key processes and documentation.

Learning Objectives:
Upon completion of this activity, learners will be able to:

Explain the different types of UR.
Describe guidelines for UR approval, UR denial, and UR partial approval.
Explain the administrative issues involved in UR.
Describe the peer-to-peer process including efforts to achieve successful collaborative discussions and documentation.
Recognize how to conduct appeal UR reviews and document decision rationale.
Apply strategies learned to several case examples.