Utilization Management for Workers Compensation

Ensures care is appropriate, cost-effective and medically necessary.

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Why Utilization Management

Utilization management (UM) is a set of techniques used by purchasers of health care benefits to manage health care costs by assessing care appropriateness before health care is provided using evidence-based criteria or guidelines. Conduent provides utilization management services for workers’ compensation programs. We offer a URAC-accredited program seamlessly integrated with case management, bill review and medication management to deliver better, optimal care that is appropriate and cost-effective.

We offer the following utilization management techniques: utilization review, clinical peer review and drug utilization review.

Utilization Review

Utilization review (UR) is the utilization management technique used by employers and claims administrators to determine if a proposed treatment requested for an injured worker is medically necessary. In some states, utilization review programs are required by law.

UR requests for authorization (RFA) are coordinated by Conduent nurses with oversight by our national medical director. Decisions on whether or not to approve a medical treatment recommended by a treating physician are based on state-mandated or evidence-based medical guidelines. Guideline examples include the American College of Occupation and Environmental Medicine (ACOEM) and ODG®.

We offer multiple levels of Utilization Review:

  • Prospective review – UR conducted prior to the delivery of the requested medical service
  • Concurrent review – UR conducted on an RFA submitted for treatment during an inpatient hospital stay
  • Retrospective review – UR conducted after medical services have been provided and for which authorization has not already been given
  • Expedited review – UR conducted when the injured worker faces an imminent and serious threat

Clinical Peer Review

A peer review involves an extensive review of the claim requester’s questions, associated medical records and other clinical information. This utilization management technique gives special focus to pre-existing conditions, compensability, causality and other relevant factors. Conduent delivers reliable decisions that are consistent with relevant standards of medical care and free of conflicts of interest associated with workers’ compensation claims.

Our services include:

  • Initial and appeal certifications
  • Complex medical records file reviews
  • Critical disability and return-to-work consults
  • Impairment ratings
  • Physician peer-to-peer

Drug Utilization Review

Drug Utilization Review is a utilization management technique designed to maintain the appropriate and effective use of medication. The systematic process involves an ongoing review of how medication is prescribed, dispensed and used. Conduent’s drug utilization review clinicians combine advanced polypharmacy expertise and data assessments  to help you tackle challenges with drug abuse, misuse and overutilization — the leading driver of workers’ compensation claim cost and duration and patient risk.

Our services include:

  • Synchronized patient management
  • Formulary review and management
  • Formal drug approval process
  • Chronic medication protocols