UTILIZATION REVIEW SERVICES
The Power of Provider-to-Provider Conversations

PM&R Utilization Review

With Briotix Health’s PM&R Utilization Review Management Program, companies don’t have to choose between ensuring the injured worker gets the best medical care and preventing unnecessary, costly treatments. Our program assists workers’ compensation claims managers in effectively managing the costs and medical necessity of therapy services, including Physical Therapy, Occupational Therapy, massage, and chiropractic services.

How is Briotix Health Different?

Briotix Health’s approach impacts the therapy outcome and utilization patterns by having like-disciplined professionals (Physical Therapists, Occupational Therapists and Chiropractors) complete the first level reviews. Additionally, our reviewers are industrial medicine specialists who have a unique understanding of work-place demands. Our value-added service of engaging PM&R providers with these Briotix Health Service Solutions Specialists (SSS) seasoned in coaching providers toward rapid functional recovery drives more efficient and effective therapy outcomes.

 

The Benefits of Our Approach

  • Having a PT, OT, or DC complete first-level reviews offers a level of qualification that other health professionals cannot provide.
  • Our providers engage with their respective professionals at the outset to ensure the common goal of fast recovery is communicated in an easy-to-understand language.
  • Briotix Health’s discipline-specific engagement provides for clinical expert certification recommendations and drives towards industry best practices.
  • Briotix Health’s SSS translates the functional requirements of the injured worker’s job for the provider and builds that into the provider coaching process.
  • Our “focus on the function” optimizes physical restoration and return-to-normal duties faster.
  • The improved outcomes and collaborative dialog between the SSS and their professional counterparts creates a unique provider-to-provider dynamic and enhances voluntary compliance with treatment guidelines.

This unique process results in significantly reduced utilization and expense of therapy and rehabilitation services along with enhanced relationships with providers that facilitate future utilization discussions.

Provider-to-Provider Conversation

As part of our Utilization Review process, we conduct provider-to-provider conversations.

This open communication between providers, therapist to therapist, chiropractor to chiropractor, often provides additional insight and information above and beyond traditional Utilization Review services.

While these conversations do not influence our certification decisions, they are invaluable in coaching providers toward best practices and provide our client with additional insight and information regarding their injured workers.

We discuss:

  • Clarification of the patient status, current treatment plan, goals and projected outcome
  • Reasons why a partial or non-certification was recommended
  • The injured worker Job Analysis/job demands
  • The need to include functional, work related tasks, status and goals in the treatment plan and documentation
  • The right to appeal and what documentation is needed to justify additional services
  • Any specific requests for information or coaching the claims manager may have
  • In WA: coaching regarding the WA liability and insurance therapy progress report form

 

How does Utilization Review Work?

  1. Compensation Claims Manager needs assistance to determine whether additional PT/OT/MT/DC treatments are medically necessary.
  2. Claims Manager contacts Briotix Health to begin the Utilization Review Process.
  3. Initial clinical review based on evidence-based medical research and clinical review criteria to determine the medical necessity of requested treatment.
  4. Peer review/Second Level Review – if the initial clinical review recommends partial or non-certification; completed by a peer of the referring provider and may include a peer to peer conversation.
  5. Appeal/Third Level Review – if requested following a partial or non-certification decision
    *As value-added service the Initial Clinical Reviewer may conduct a provider-to-provider conversation to review clinical status and discuss the certification status and convey information received back to the case manager.

RESULTS & OUTCOMES

Public Agency Reduces Therapy Utilization by 70%, Promoting Efficiency in Results

A self-insured public agency that internally manages claims was suffering from high physical therapy, occupational therapy, massage, and chiropractic utilization rates as a result of excessive visits per case. While the claims manager and his UR staff recognized the organization was overspending on therapy because of high utilization rates, they did not have specific knowledge on clinical practices to determine the necessity of the therapeutic visits and therefore could not evaluate if unnecessary visits were being approved.

Briotix Health Solution

This company opted to begin having therapy requests evaluated through an external utilization review process from Briotix Health. The external review process was done with the goal of ensuring patients received medically necessary treatment for a positive outcome while reducing unnecessary, excessive therapy visits based on industry best practice recommendations.

Results

Over one year of the visits requested, only 29% were determined medically necessary and the remaining 71% were deemed as excessive. An average of seven visits per referral was eliminated from treatment timelines without negative impact on return-to-work or clinical outcomes. The service promoted efficiency while still ensuring positive results.

Overall, the organization saved $336,960 and saw a 4:1 ROI. 

Briotix Health is URAC Accredited

Founded in 1990, URAC is the independent leader in promoting healthcare quality through leadership, accreditation, measurement and innovation. URAC is a nonprofit organization using evidence-based measures and developing standards through inclusive engagement with a range of stakeholders committed to improving the quality of healthcare. Our portfolio of accreditation and certification programs span the healthcare industry, addressing healthcare management, healthcare operations, health plans, pharmacies, telehealth providers, physician practices, and more. URAC accreditation is a symbol of excellence for organizations to showcase their validated commitment to quality and accountability.

 

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