Earlier this year, EK Health was selected at random to undergo a Utilization Review audit by the California Division of Workers' Compensation (DWC). The DWC conducts audits of claims administrators and utilization review organizations (UROs) to ensure they have met their obligations under the Labor Code and the administrative director's regulations. The audits focus on key aspects of the UR process, including timeliness, content and delivery of responses to requests for authorizations of treatment (RFAs) for injured workers.
As part of the rigorous audit process, EK Health provided over 1,000 RFAs (request for authorization) to the DWC, of which a certain percentage were randomly selected for detailed review. At the conclusion of the DWC audit, EK Health’s Utilization Review program received a performance rating of 100%. This is an improvement over EK Health’s previous DWC UR audit rating of 99.4% in 2018.
Dr. Glenn Crafts, EK Health’s Assistant Vice President of Utilization Review & Quality Assurance explained, “the EK Health UR team is dedicated to exceeding quality expectations while consistently meeting regulatory requirements set forth by the DWC. EK Health UR applies a rare element of detail within the industry that comes from each healthcare professional that touches medical treatment requests and couples that with our advanced proprietary software, Ahshay®, to achieve these remarkable audit outcomes on a regular basis”.
A key challenge for claims administrators and UROs is maintaining compliance with new legislation that impacts the workers’ compensation industry. “With the help of our in-house counsel, we are capable of staying ahead of regulatory changes and shifts we have seen with SB1160's exempt treatment and drug formulary, and created systematic approaches to delivering the most appropriate medical necessity determination that checks all of the necessary boxes”, explained Dr. Glenn Crafts.
Kerri Wilson, EK Health’s President & Chief Operating Officer added "as indicated by the most recent outstanding DWC audit score, producing quality results remains the cornerstone of our Utilization Review service delivery. I am very proud of our team of professionals who focus on doing the right thing, making strong clinical decisions and delivering the best for our clients and their injured employees".
EK Health has an extensive and experienced working relationship with the DWC that is based upon our continued commitment to being in full compliance with all DWC requirements. Further, EK Health’s audit record with the DWC is a testament to our ability to provide a high quality of Utilization Review service to all of the clients we serve. EK Health looks forward to maintaining our quality & excellence as we continue to transform managed care.