Workers' Compensation & Utilization Management
November 20, 2018
Beginning in 1908, federal and state governments established workers’ compensation (WC) programs for employees in hazardous work environments. Programs were enacted in all 50 states by 1949, and the social insurance program is still regulated state-by-state today. That is not to say, however, that nothing has changed. Workers’ compensation programs have expanded and improved significantly to promote workplace safety and patient advocacy to protect both the employee and employer.
With an employer's WC program, an injured employee can file a claim to dispute the compensation and medical care coverage for the workplace injury. Claimants also have the ability to request an appeal of the WC claim, which is where independent review organizations (IROs) come in. Allowing a third-party organization to re-evaluate the claim advocates for evidence-based medicine and employees’ access to quality healthcare. Considering the National Academy of Social Insurance reported workers’ compensation in the U.S. covered 138.3 million jobs and paid $61.9 billion in benefits, proper review of claims is paramount for insurers and employers.
With reforms of states' WC programs, one of the changes includes a claimant’s ability to appeal the denial of the claim using a third-party organization. This appeal process can be conducted by an external review organization to evaluate the medical treatment and make a decision to accept or overturn the denial. This is an alternative to a claimant appealing the WC claim in court.
IROs step in as an unbiased third party that reviews WC and disability claims. The physicians that are contracted by IROs give evidence-based reviews for these claims. The complete medical care of the injured employee is reviewed, including treatment, medication, procedures, and rehabilitation by the original medical provider. The reviewer then makes a recommendation based on the findings to accept or overturn the denial. Outsourcing to an IRO provides an improved process for appeals and avoids costly, time-consuming litigation to keep claims on track.
Aon’s 2016 Health Care Workers' Compensation Barometer Report highlights factors that affect the future of WC, such as an aging workforce, patient safety, and workplace violence. The changing landscape of healthcare and state-by-state regulations add many challenges for the future of WC and disability insurance. At AMR, our experts are well-versed in WC updates, including state WC program reforms and privatization.
AMR is URAC-accredited and compliant with state and federal requirements for appeals and medical necessity recommendations, in addition to DOL/ERISA, ACA, State Department of Insurance and Workers’ Compensation mandates. Our workers’ compensation and disability reviews effectively process and handle claim disputes to keep them on track through our proprietary platform that streamlines the workflow of third-party reviews. The client portal offers a secure platform to assist client operations through fast processing, reporting and specialization of WC claims.
Additionally, our network of board-certified physician reviewers are compliant with WC regulations in all 50 states. Our technology matches physicians by specialty and subspecialty to the original provider, which ensures extensive knowledge of all details in the claim. The physician reviews are guided by our company’s belief that every patient should receive quality healthcare, including effective treatment for an employee's safe return to work.
To learn more about AMR and the workers’ compensation and disability review services offered, please check out the AMR Blog.
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