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Effective Health Systems Releases Study on the Effectiveness of Adjuster Decisions Regarding Medical Pre-Authorization Requests

James Schlueter, President, Effective Health Systems (www.effectivehealthsystems.com), reported a study that evaluated the effectiveness of experienced workers compensation claims adjusters at determining whether a medical treatment request should be approved or escalated to a higher-level review. The study found the effectiveness of adjusters in making a correct decision was less than would be expected from flipping a coin.

The study involved a retrospective review of 6,250 medical requests submitted to workers compensation payers for approval. Seventy-percent (4,513) requests were from California, the remainder came from 36 other states. Each request had a defined diagnosis code (ICD9) and a medical code (CPT, HCPCS). In each of these instances, a claims adjuster followed their internal practices to either authorize the request or escalate it to a higher-level medical review.

The data was subsequently processed through EHS’ BaseLine technology. The Pre-Authorization Decision application within the BaseLine platform collects the diagnosis code, the medical code, and number of treatments/procedures being requested; it also compiles historic claim data to account for previous approvals. Then it bounces the request off national evidence-based guidelines, such as ODG, ACOEM or state specific guidelines. The application incorporates specific client customizations to the guidelines to control for unique items such as high cost procedures or surgical requests, where regardless of the evidence or number being requested, a higher-level review is just good practice.

The adjusters authorized 4,546 (73%) of the medical requests and sent 1,704 (27%) of the requests to a higher-level review. BaseLine found that only 2,696 (43%) should have been authorized at the adjuster desk, while 3,555 (57%) should have been escalated to a higher-level review.

Digging deeper into the data the retrospective review showed that of the 1,701 requests that the adjusters escalated to UR, the adjuster should have authorized 715 (42%) of the requests; while 986 (58%) met the evidence standards for the investment in UR.

On the other hand, of the 4,546 requests that the adjusters authorized, only 1,980 (44%) should have been authorized at the adjuster’s desk. Remarkably, 2,566 (56%) of the requests authorized by the adjuster had a diagnosis/treatment code combination that represented a significant likelihood that it would have been modified in some fashion by UR had it been escalated.

According to Schlueter, “The bottom-line is that adjusters are not medically trained professionals but they are being asked to make complex medical decisions in the name of operational efficiency. Without the support offered by BaseLine, the outcomes with this scenario are simply not effective. BaseLine bridges the gap between operational efficiency and organization effectiveness. BaseLine streamlines workflows and provides critical information and guidance adjusters need to do what they do best.”

For a discussion regarding the potential financial costs of this model on payers and TPA’s, EHS has prepared a complimentary white paper available by sending an email to [email protected]. Please put the words “Adjuster Effectiveness” in the subject line and include your contact information.

EHS released an abbreviated mobile-accessible version of the BaseLine pre-authorization decision tool. It is offered on a free-trial basis. The mobile application is a demonstration of how the API web-services can integrate BaseLine functionalities into the backend of any existing technology. To access a mobile app for free: https://pa.effectivehealthsystems.com/

About Effective Health Systems:

Effective Health Systems, (www.effectivehealthsystems.com) delivers technologies that help claims professionals do their jobs better. BaseLine is an inexpensive, quickly deployable and non-disruptive innovation to claims management. To learn more visit our website www.effectivehealthsystems.com.

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