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Utilization Management

Utilization Review Services - Workers Compensation

Utilization Review

URAC Accredited Independent Review Organization

Utilization Review manages medical aspects of claims in conjunction with ensuring injured workers are provided with timely and appropriate medical care. Over-utilization of medical treatment is a driving factor in the overall cost of a Workers’ Compensation claim. SFUR, through the use of licensed nurses, board certified physicians and application of data driven evidence-based guidelines, addresses costs through a proactive approach.

Summary

The continuation of clinicians’ privileges at a hospital is based on the quality and safety of care delivered to patients. The review of privileges is a critical, timely and sensitive process. This responsibility falls on the medical executive committee, which oversees the performance of all practitioners who are granted privileges and makes recommendations as to which medical staff members should receive new or maintain existing privileges. SFUR fits in this process by provider reviewing physicians representing the following specialties.

OUR CURRENT PHYSICIAN SPECIALTIES

  • Anesthesia
  • Bariatric Surgery
  • Cardiology
  • Cardiothoracic Surgery
  • Colon Rectal Surgery
  • Emergency Medicine
  • Family Practice
  • Gastroenterology
  • General Surgery
  • Hematology
  • Infectious Disease
  • Internal Medicine
  • Interventional Cardiology
  • Neonatology
  • Nephrology
  • Neurology
  • Neurosurgery
  • OBGYN
  • Ophthalmology
  • Orthopedic Surgery
  • Otolaryngology
  • Pediatrics
  • Plastic Surgery
  • Psychiatry
  • Pulmonology
  • Polysomnography Radiation Oncology
  • Radiation Oncology
  • Thoracic Surgery
  • Urology
  • Vascular Surgery

Example

Provider organizations including rural hospitals, large rural delivery networks and ambulatory surgery centers, reach out to SFUR to provide this review because they are not able to source this function internally at a reasonable rate.

SFUR Reviewing physicians typically complete a report based on the  review of the medical record:   Ex.= Excellent, Avg.= Average, BA = Below Average; NI = No Information

Medical knowledge
– Basic medical/clinical knowledge
– Knowledge in specialty
– Technical and clinical skills

Clinical judgment
– Basic clinical judgment
– Availability and thoroughness of patient care
– Appropriate and timely use of consultants
– Quality/appropriateness of patient care outcomes
– Appropriateness of resource use (e.g., Lab, x-ray.)
– Clinical pertinence and completeness of medical record documentation

Communication skills
– Overall communication skills
– Verbal and written fluency in English
– Clarity/legibility of records
– Responsiveness to patient needs

Interpersonal skills
– Ability to work with members of healthcare team
– Rapport with patients
– Rapport with families

Professionalism
– Timely documentation of medical record
– Demonstration of ethical standards in treatment
– Maintenance of patient confidentiality

System-Based Practice
– The H&P is complete and accurate
– Effective and thorough problem list completed