Utilization review is effective at controlling medical utilization in workers compensation and more and more states are adopting treatment guideline strategies.

However, UR is not without its problems -- it is expensive, inefficient and over-utilized.  A few months ago, Maddy Bowling, a noted Chicago-based consultant stated in Risk & Insurance:

"It is no longer acceptable to apply ... utilization review ... across an entire book of business. It is costly, and it is not targeted enough..."  Maddy Bowling.

Smart UR is a transparent next generation technology for UR.  Applied at the claims level, it delivers a unique targeting capability to the UR process.  Smart UR can cost-effectively identify and approve requests that will fall within guidelines; while sending requests that will likely fall outside the guidelines to any URO our clients choose to use.  Important to risk managers, Smart UR delivers consistent and reliable decisions at the adjuster level to keep errors at a minimum.  The result is that claims people can stay focused on claims management rather than pushing UR paper.

Smart UR is a low-cost application that allows risk managers to maintain the sentinel effect of UR to contain medical overutilization practices while not overloading the system with unnecessary and expensive URO reviews. Smart UR technology is the more intelligent option to contain the costs associated with WC medical utilization.

Moody's identified that 2009 cash liquidity will be a major issue for many companies.  CFO Magazine noted that with the tightening economy there will be growing pressures for internal audits to identify areas to develop business process improvements.  SMART UR's management technology puts the control of the UR process in the hands of the Insured, not the URO vendor -- see our tech specs page.

SMART UR is a service that smart managers will rapidly bring into their management system.

A simple to use highly-effective cost-efficient web-based technology.

Uses copyrighted and proprietary medical algorithms targeting medical requests that can target medical requests that fall within evidence-based guidelines -- about 50% - 70% of all requests.

Designed to be applied at the claims adjuster level; it may be opened to selected medical providers to further increase the efficiency and effectiveness of the UR process and encourage higher-quality practitioners to treat your injured workers.

Smart UR is not directly associated with any URO - so there is no conflict of interest. It is capable of electronic interface with any internal or external URO - so there is no need to change existing vendor relationships.

Smart UR will grant an insured's URO access privilege to the system to conduct URs at no charge.

Transaction pricing plan means there are no immediate upfront technology investment/transition costs or on-going maintenance and upgrade costs.

The Issue

The outcome goals of the client and vendor in  UR programs are misaligned.

Insureds seek cost-containment via the ability of UR to control of excessive utilization of medical procedures. 

UROs are in business to maximize shareholder wealth via the conduct of utilization reviews. UROs have an incentive to be efficient, but there is no incentive to limit their work-flow.  

The alignment issue arises in that the UROs, not the insured, control the intake flow process.   Subsequently, 80% of the reviews conducted are approved by the URO and are thus non-productive to the insured.

This is a problem...

Based on data from audits conducted by the CA state DWC as of 12/08 gross UR outcomes are as follows:

76% approved;
   7% modified;
   2% delayed; and
16% denied.

These findings are reflected in a 2006 Bickmore Study on the effect of legislative reforms on CA WC Insurance Rates. (see section III, pg 14)

Eighty-percent of the insured's investment in traditional UR is a non-productive expense.  At the average rate of $85 per, the financial waste is substantial -- not to mention the impact on providers, injured workers, claims people...