Towards the end of 2019, EK Health's and one of its clients were selected at random for a routine Utilization Review (UR) audit investigation 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. At the conclusion of the audit investigation process, a performance score is calculated and any penalties and/or violations are cited.
As part of the audit process EK Health and its client provided the DWC with a large number of RFAs (request for authorization), of which a certain percentage were randomly selected for detailed investigation. At the conclusion of the DWC audit, EK Health’s Utilization Review program received an overall performance score of 100%. To date, EK Health and their UR clients have underwent a total of 28 DWC UR audits, with the 7 most recent audits also achieving a 100% score and 20 of the 28 audits having had the same perfect score, with a cumulative score of 99.6%.
“Our Utilization Review team here at EK Health works with persistence and deliberate intent to providing the highest quality medical necessity determination.” said Dr. Glenn Crafts, EK Health Assistant Vice President of Utilization Review. He explained further, "What this means, is that our team is dedicated to always keeping everyone in mind from the injured worker to the claims admininstrator, and of course the physician rendering care to get the injured worker well as quickly as possible. Our philosphohy to expedite UR decisions hinges on balancing the highest quality physician reviewer's rationale that consistenly and approrpiately applies the manadated hierarchy of medical treatment guidelines so the most justified determination is made the first time. It is this bridge between clinical excellence, quality and efficiency that is the biggest differentiator for EK Utilization Review and it is evidenced by our consistent DWC UR audit scores."
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 with our vision of transforming managed care.