Friday, January 4, 2013

Out of State UR - I Don't Understand

I know this post is going to provoke some argument and discussion so here goes: I don't understand why it is so important that a medical treatment review physician be located within the state that the claim necessitating review originates.

The issue has come up in Illinois, which just recently passed its utilization review statute and is in the process of implementing regulations.

The Illinois statute, known as the Managed Care Reform and Patients’ Rights Act, has no mandate that reviews be done in state, but regulators have raised hackles in the state with a Department of Insurance bulletin saying that utilization review of Illinois cases must be conducted within the state's borders.

This debate has been going on for some time in Texas, California and other utilization review states.

David Menchetti of Cullen, Haskins, Nicholson and Menchetti in Chicago, a claimant's attorney, told WorkCompCentral, that reviewers "need to be familiar with how medicine is practiced in Illinois...which may be different from how it's practiced in Indiana or India."

Dr. Robert L. Weinmann, of San Jose, Calif., an openly critical and long-time advocate of requiring in-state residency for reviewing doctors in the California system argues that physicians who are not licensed in California will not be responsive to the needs of California residents.

Because reviewing doctors out of state can't be controlled by California licensing authorities, insurance companies are then "free to scour the country" for doctors who are willing to give favorable reviews to the insurers, Weinmann told WorkCompCentral.

I'm not convinced - the only real requirement is that the reviewing doctor follow the treatment guidelines as adopted by a particular state system, and if there is no guideline for the proposed treatment (hardly the case, very few ailments, diseases or injuries aren't covered by some guideline) then other protocol can be followed.

And most states have some sort of secondary review process where a treatment protocol that was originally denied can be "appealed" which provides the party denied the treatment an opportunity to raise other medical evidence of appropriateness.

In Texas, utilization review companies must be licensed in the state, and use health care providers who are licensed in Texas. However, the companies and providers may be located outside of the state.

That's a nice compromise, but I still don't see licensing within a particular state as being any assurance of quality or the ability to regulate the process.

Utilization review is like having an editor - the process is all paper (okay, probably digital now) driven. The reviewing doctor has no relationship with the patient, no face time, no contact other than the assignment to review a file and the proposed treatment then render an opinion based upon approved guidelines whether the treatment is warranted or not.

Last I checked, human anatomy and biology has not changed from state to state. The laws are different, but the reviewing physician isn't being asked to make a legal determination. The practice of medicine may be different in India, as noted by Menchetti, but not if its "Western" medicine.

Leaving carriers "free to scour the country" for doctors who are willing to give favorable reviews as an objection doesn't cut it either, in my opinion. If a carrier is predisposed to deny a treatment request there are plenty of in-state physicians who would be willing to opine such (and visa versa - just as many for the claimant side to opine the opposite). It doesn't matter where the doctor is located.

Utilization review companies, like most everything else in workers' compensation, deal in volume. Volume is what makes profitability in the highly regulated atmosphere of workers' compensation possible, from policy selling to medical management to claimant representation. Workers' compensation on the business side is all about volume.

When dealing with the economics of volume, cost control is critical, and if a review company based in Arizona using doctors from Nevada charges less for a review of an Illinois case than a Chicago physician then the market will demand that course of action. To make utilization review economically viable a review company needs to be as efficient as possible, which may mean having out of state physicians doing the work because it is cheaper.

How does a claimant, and proposed treatment, in California differ from the same circumstances in Illinois other than perhaps the actual standard of review (which is all in writing)? The reviewing physician has no doctor-patient relationship so there is no malpractice issue, thus the licensing of the physician in the review state is irrelevant.

A reviewing doctor or organization that gets routinely overturned on appeals is not going to be used for long because the payor is not going to tolerate the unnecessary expense of review that is ineffective.

I don't know this for fact, but my assumption is that general health insurance has been down this path a long time ago, and that treatment decisions are reviewed by physicians not located in the same state (perhaps even country) in which the requested treatment is being sought. Perhaps someone can enlighten me.

Mandating that utilization review be conducted by physicians located in the state doesn't make any logical sense. I'm sure someone will try to enlighten me.


  1. I perform UR for Calif and other states, and am licensed in Calif with lots of experience treating in Calif. It makes no difference what state I am reviewing. All of my reviews are the same in concept: use the available guidelines, evidence, and records, and render a decision regarding medical necessity. All talk about the necessity of in-state reviewers is irrelevant and unnecessary. Bottom line, no doctors like to be reviewed by UR, but it is convenient to complain about out of state reviewers rather than focus on the actual medical issues at the core, which is where the focus should be.