Same Day Utilization Review Cases

From time to time in our Utilization Review (UR) programs, we see an increase in what we call “same day” cases. These are different than concurrent cases/reviews, which are requests for treatment as the injured worker is receiving the treatment. An example of a concurrent case would be a request for additional days at the hospital while the patient is still hospitalized or receiving treatment.

So what do we mean by same day utilization review cases? Same day cases are when the UR request is received on the regulatory due date or very late on the day prior to the regulatory due date. Sometimes these represent true rush cases which have been requested by the treating provider, but more often, there is some delay in transition of the request from the adjustor desk to the UR unit.

We have seen an increase in same day cases with the implementation of the CA Formulary that went into effect on January 1, 2018. The goal of every organization should be to get UR requests into the hands of their UR staff as soon as possible. Any delay in this process can cause 1) delays in treatment and care for the injured worker and 2) missing regulated turnaround times.

If your organization is struggling with a similar atmosphere, Shearwater Health can help. Our Utilization Review teams are trained to react quickly and efficiently to prioritize same day cases to make sure these can be appropriately addressed within the regulatory turnaround time including peer intervention as needed.

Other long-term solutions we provide to meet this goal include:

• Claims Assistant Support by Philippine-licensed nurses so that the delays from the adjuster desk to the UR unit can be mitigated.
• Peer Review Prep of cases so that the peer reviewer can more efficiently address the medical necessity of cases.