Utilization Review Services - Workers Compensation
Pre-Certification & Pre-Authorization
Pre-certification / Pre-authorization refer to the process by which a patient is pre-approved for coverage of a specific medical procedure or prescription drug.
At SFUR we implement a proactive process that can be used in the medical management of a workers’ compensation claim. This review provides an evidence-based opinion of medical necessity for a proposed treatment based on submitted medical documentation and evidence-based treatment guidelines.
Summary
Our approach at SFUR uses licensed nurses, board certified physicians and data driven evidence-based guidelines, to help reduce or avoid costs by being proactive rather than reactive.
SFUR offers our payer customers a simple electronic requests for medical necessity. After the initiation of a review and throughout the process, the SFUR experts communicates with the adjuster to ensure the most appropriate determination of medical necessity is made.
Our customer partnerships provide the highest level of service and expertise to enhance a payers’ cost containment strategy.
Example
A very common billing abuse involves arthroscopic shoulder surgeries, often at Ambulatory Surgery Centers (ASCs). An example would be where a financial partnership exists between the surgeon doing the procedure.and the company that charges an exorbitant amount (e.g. $10,000) for a postage-sized piece of amniotic membrane.
SFUR sees cases where an ASC and/or physician charging $1,000’s for amniotic fluid ( baby urine) injections. The best approach would be to negotiate a global bundled price for the procedure so there is no incentive to perform or charge for unnecessary things, unbundle codes, use unproven “implants”, etc.
If you are not able to authorize a bundled price, then create wording on the authorization that addresses the rejection of experimental or investigational procedures or materials such as amniotic membrane, amniotic fluid, unproven “implants”, stem cells as part of “Tissue Bone Matrix Bio4”, which is experimental and investigational, etc.
Over the years SFUR has identified, quantified and successfully negotiated out medically questionable provider billings and procedures saving our customers millions of dollars.
Typically, the cost of a SFUR Pre-Certification and Pre-Authorization service is a faction of the procedure and/or supply that could be avoided. This has been an attractive return on investment for our customers, typically in excess of 1000%.