Utilization Review: More Than Just a 'No' Machine






Utilization Review’s job is to keep the “gears” of proper treatment running smoothly, but it’s often unfairly seen as a wrench in the process.


Utilization Review (UR) often gets a bad rap, perceived merely as a bureaucratic gatekeeper in the workers' compensation system. While these programs are often misunderstood, their benefits extend far beyond mere cost containment. Glenn Crafts, Assistant Vice President of Utilization Review, and Kerri Wilson, President and COO, shed light on the multifaceted nature of UR, emphasizing its pivotal role in ensuring appropriate care and provider accountability.


"UR at the core is about clinical appropriateness, ensuring injured workers receive the right treatment at the right time," Crafts emphasized. “Contrary to the misconception of Utilization Review as a burdensome process, it serves as a guardian of patient interests and employee experiences, along with cost containment, by mitigating unnecessary treatment. Wilson echoed this sentiment, stating, "UR is simply not a 'no' machine; it enhances patient outcomes and quality of care."


The goal of UR is to ensure that requested treatment is supported by evidence-based medicine (EBM) guidelines, acting quickly to ensure that treatment is appropriate and eliminating unnecessary procedures where not scientifically supported. Wilson continued, “Objectivity is crucial, and clinician involvement is key to success. Equitable review with the absence of bias identifies patterns for both success and failure. In actuality, sometimes saying “no” is truly in the best interest of the patient. UR ensures that an appropriate standard of care is delivered. With medical guideline-supported treatment, the desire is the delivery of appropriate treatment that offers the best possible chance for successful recovery.  This makes utilization review a useful tool in all jurisdictions and an important part of the overall claim management process.”


Find a UR partner that upholds the same ideals you have for your program. Unwavering dedication to transparency, accountability, and adherence to legislative and client-specific requirements are critical. Crafts adds, "Our programs facilitate cost containment with focus on transparency, quality, and provider collaboration/education." The strongest UR program is one where providers are treating appropriately, thus limiting the number of denials. EK Health’s goal is a decreased number of denials in UR.


In essence, Utilization Review programs can represent a beacon of efficiency and effectiveness in the realm of utilization management. By leveraging objectivity, rigorous oversight, and a commitment to excellence, comprehensive reviews can deliver tangible and quantifiable results, playing a part in improved patient care and overall outcomes.  Utilization Review transcends its stereotype as an administrative hurdle, playing a vital role in patient advocacy and provider accountability.


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