The utilization review process for workers' compensation claims is ripe for automation. Commonly viewed as a nurse-led process, the practice of determining whether healthcare is medically necessary for an injured worker has remained relatively unchanged for decades.  Requests for authorization are submitted, a nurse compares the requested care against evidence-based medical guidelines, and a determination is issued.

The determination is a tool for the treating provider, the claims examiner, and the claimant.  Applying the determination during the actual delivery of care is traditionally accomplished by a person, typically a claim examiner or adjuster, or by a medical bill reviewer or auditor, but rarely is it done through technology-enabled automation.

Why automation is good for UR

Automation can have many touchpoints in the utilization review workstream. One of the first is the request intake process. Unlike bill review, the Request for Authorization (RFA) form is not standardized across the United States. Some states have very specific requirements for submitting the RFA, whereas other states offer little or no guidance on form submittal, which leads to a very manual process for data entry into a utilization review system. This is changing with new UR platforms that combine optical character recognition tools and automated intelligence or AI. The faster and more effectively that requests can be submitted for review, the sooner claimants can receive appropriate care.