This summer, workers’ compensation providers in California will be able to test out new software that lets them get authorizations for patient treatments in real-time – through their electronic medical records – rather than waiting several days for decisions to come via fax.
Dr. Dinesh Govindarao, chief medical officer for the State Compensation Insurance Fund, said his agency decided to fund development of the software because leaders wanted to get care approved faster for injured workers. State Fund, the second largest workers’ compensation insurer in California, serves state employees and employees of private-sector companies that can’t get coverage from a commercial carrier.
“If the system is more efficient and patient care is rendered faster, then folks are hopefully getting back to work sooner, and that will then really reduce indemnity cost (for disability pay),” Govindarao said, “and also if care is not being delayed, hopefully even medical costs will go down because they’re getting care faster and there’s maybe less risk of complications.“
Although State Fund developed the new software, known as UR Connected, Govindarao said, it is something they believe could benefit any workers’ comp insurer, and he is hoping that other insurers will want to adopt it.
UR Connected integrates with and leverages existing information systems in the medical providers’ offices, so neither the providers nor their staff have to go offline and fill out paperwork to request approvals for patient treatment, said J.R. Long, an executive with Conexia, the software company that developed UR Connected for State Fund.
Govindarao said: “What we wanted to do was change that up, so in real time, the physician who is requesting that, they would right then and there get a response: Either yes, go ahead and treat, or we need to escalate this for utilization review.”
In utilization review, insurers look at whether to provide health care services to patients. During this process, they look at whether a treatment falls within evidence-based medical standards of care, whether it’s something covered under the insurer’s policies, and the costs of the service versus the anticipated benefit to the patient.
With UR Connected, Govindarao said, evidenced-based medical procedures would get approved while patients are still in the exam room if State Fund covers them, and requests that require utilization review will be sent to the appropriate personnel more quickly.
Long added: “You’re able to manage by exception, so the things you need to get involved in, you can put your resources toward that as opposed to the events or activities that today are happening in this...manual fashion. You can redirect those staff to more value-added activities both for the insurer and ultimately for the provider and the patient.”
Roughly 11 percent of California workers have workers’ compensation through State Fund, said Jonathon Tudor, an agency spokesman. The agency processes tens of thousands of claims annually for its 103,000 clients, he said, and right now, it has roughly 85,000 open claims, about 7,200 of which are in the four-county Sacramento region.
Stuart Sweetser, who works in State Fund’s medical claims division, said that, as the technology gets more widely adopted, some of State Fund’s staff will get different assignments but that State Fund does not foresee any layoffs.
Govindarao said that “the manual tasks probably will never go away. For that to happen, we’d have to have 100 percent adoption with every provider out there, which I think is probably not going to happen. But I think, if we have over 70-80 percent as a target, down the road.”
State Fund is paying Conexia to help ensure the UR Connected system can be smoothly adapted to the various information systems that doctors, hospitals and other types of medical practitioners use, Govindarao said, and they hope to get large groups and high-volume practitioners set up with the system soon.
If providers aren’t ready to integrate their information systems with UR Connected, Govindarao said, they have the option of going through a website portal to request approvals for treatments. The plan, he added, is to also integrate with bill payment to try and get practitioners paid faster.