Utilization Review in Workers’ Compensation
ACOEM Member Price: $99
Non-member Price: $129
Utilization review (UR) is a process that assesses aspects of a treating provider’s care plans and then provides recommendations to payors/insurance carriers, third party administrators, etc., concerning the appropriateness of the proposed care. UR has become an integral part of medical practice and has influenced medical care within the workers’ compensation (WC) system and is mandated in several states and jurisdictions. This 3-hour online training will discuss quality and value-based standards for UR and UR documentation, guidelines, regulatory issues and resources, documentation needs to support decisions, improve outcomes, and decrease conflicts. It will also review several case examples to apply key processes and documentation.
Upon completion of this activity, learners will be able to:
1. Explain the different types of UR.
2. Describe guidelines for UR approval, UR denial, and UR partial approval.
3. Explain the administrative issues involved in UR.
4. Describe the peer-to-peer process including efforts to achieve successful collaborative discussions and documentation.
5. Recognize how to conduct appeal UR reviews and document decision rationale.
6. Apply strategies learned to several case examples.
Faculty and Disclosures
DOUGLAS A. BENNER, MD, FACOEM
Dr. Benner is Chief Medical Officer at EK Health where he works with EK Health’s leadership team in the development of the company’s managed care programs. He is also responsible for recruiting, training and supervising all physician reviewers, and provides oversight of managed care policies and procedures. Previously, he served over 30 years as Coordinator of Occupational Health for Northern California Kaiser Permanente. Named among “The Most Influential People in California Workers’ Compensation” in 2010, Dr. Benner is a diplomat of the American Board of Preventative Medicine in occupational medicine and was certified as an Independent Medical Examiner and Medical Review Officer.
RAJIV DAS, MD, MPH, MS, MRO, FACOEM
Dr. Das is Medical Director for Safeway, Inc., Vons and Albertsons Stores nationwide (300+ facilities/90,000+ employees). In this role, he manages medical providers, overseeing treatment and utilization review (UR) issues. He has provided direct patient care for over 15 years as well as performed utilization review for over 10 years. He also served as a QME. Dr. Das is Medical Director for Benioff UCSF Children’s Hospital Oakland Employee Health Services. He is on the board of the Western Occupational and Environmental Medical Association and is board certified in occupational medicine, physical medicine, and rehabilitation and pain medicine.
MICHAEL ERDIL, MD, FACOEM
Dr. Erdil is a board-certified occupational medicine physician with Occupational and Environmental Health Network in Marlborough MA, and an Assistant Clinical Professor at UConn Health Division of Occupational and Environmental Medicine. He is also serving as Medical Advisor and Educator at UConn DOEM for the Retaining Employment and Talent after Injury/Illness Network (RETAIN CT) system level return to work intervention program in Connecticut funded by the U.S. Dept of Labor, Office of Disability Policy. Dr. Erdil is collaborating on the ACOEM Work Group to revise the ACOEM document “Preventing Needless Work Disability by Helping People Stay Employed.” Dr. Erdil has been a contributor to several evidence-based treatment guidelines for low back and musculoskeletal disorders including the Agency for Health Care Policy and Research 1994, American College of Occupational and Environmental Medicine 1997, ODG by MCG Guidelines 2005-date, UpToDate 2016-date and Dynamed Plus 2018-date. He has lectured widely about the importance of evidence-based care in the management of low back pain and musculoskeletal disorders, prevention of musculoskeletal disorders and disability (including co-authoring the Health Effects Section of the Preamble to the Proposed OSHA Ergonomics Program 1999, 2000), prevention of opioid adverse events (including co-authoring CT Dept. of Public Health’s white paper The Opioid Crisis and Connecticut’s Workforce 2019) and has special interests in patient education and shared decision-making. Dr. Erdil was the recipient of the 2016 Harriett Hardy Award from the New England College of Occupational and Environmental Medicine for his contributions to the field of occupational medicine.
ADAM L. SEIDNER, MD, MPH
Dr. Seidner is Chief Medical Officer for The Hartford. He is responsible for The Hartford’s strategy and policy across all lines of business with a particular focus on workers’ compensation and disability management. He has worked on many public health issues over the years including indoor air quality, opioid epidemic, pandemics, and catastrophic events. He is responsible for medical policy development, quality assurance and improvement. Areas of research include vaccine development, worksite health promotion, return to work and stay at work, integrative pain management, and fitness for work. He and The Hartford have worked on the Retaining Employment and Talent after Injury/Illness Network (RETAIN-CT) project through a grant from the U.S. Department of Labor's Office of Disability Employment Policy (ODEP). Dr. Seidner is board certified by the American Board of Preventative Medicine in occupational and environmental medicine and American Board of Family Medicine. Dr. Seidner is the 2020 recipient of the Comp Laude Award for Doctor/Physician.
JILL A. ROSENTHAL, MD, MPH, MA, FACOEM
Dr. Rosenthal, Senior Vice President and Chief Medical Officer at The Zenith Insurance Company, has been with Zenith since June 2010. She received her B.A. from Duke University where she also earned a Certificate in the Biopsychosocial Approach to Health and Human Development. Dr. Rosenthal received her M.D. from the University of Illinois. In addition, Dr. Rosenthal earned both a M.A. and a M.P.H. from the University of Illinois. She is board certified in occupational medicine and licensed to practice medicine in Florida, California, and Texas and is an AME through the FAA. Dr. Rosenthal has served as the Medical Director for General Motors in Doraville, Georgia; for Midwest Generation in Chicago, Illinois; for Evanston-Northwestern Hospital’s Employee Health Department; and for two Johnson and Johnson companies, Cordis and Microtyping Solutions. Dr. Rosenthal was the Area Medical Director for Concentra in South Florida where she also acted as the Medical Director and Infection Control Officer for the City of West Palm Beach’s Fire and Police Departments. In addition, she has served as a Physician Advisor for SBC-Smart Disability Program, Broadspire, General Electric, and Federal Occupational Health. She was on the Board of Directors for the American College of Occupational and Environmental Medicine of which she is a fellow. Dr. Rosenthal is the past Chair of the Legislative Committee of the Western Occupational and Environmental Medical Association and is a past president of the Florida Association of Occupational and Environmental Medicine. Florida’s Surgeon General appointed Dr. Rosenthal to a second term on the Florida Prescription Drug Monitoring Program Foundation Board of Directors and is the Chair of its Executive Committee. Dr. Rosenthal is a member of the AMA’s CPT Advisory Committee, an Affiliate Assistant Professor at the University of South Florida Occupational Medicine Residency Program, and a member of the GMEC for the Palm Beach County Preventive Medicine/Public Health Residency Program.
TANISHA K. TAYLOR, MD, MPH, MBA, CIME, FACP, FACOEM
Dr. Taylor is Chief Medical Director for RWJBH Corporate Care in New Jersey where she has been instrumental in improving outcomes for workers’ compensation clients for both her organization as well as for clients and oversees employee health services. She is Clinical Assistant Professor in the Department of Environmental and Occupational Health at Rutgers School of Public Health. Dr. Taylor has served on ACOEM’s Board of Directors and is currently ACOEM Treasurer. She is board certified in occupational medicine and internal medicine and is also a Medical Review Officer and listed on the FMCSA National Registry of Certified Medical Examiners.
Utilization Review Subcommittee under the auspices of the Council on OEM Practice
Melissa A. Bean, DO, MPH, MBA, FACOEM (Co-Chair)
Robert C. Blink, MD, MPH, FACOEM (Co-Chair)
Douglas A. Benner, MD, FACOEM
Rajiv Das, MD, MPH, MS, MRO, FACOEM
Michael Erdil, MD, FACOEM
Stephen Levit, MD
David W. McKinney, MD, MPH, FACOEM
Chang Rim Na, MD, MPH, FACOEM
Lee Okurowski, MD, MPH
Charles P. Prezzia, MD, MPH, MMM, FACOEM
Jill A. Rosenthal, MD, MPH, MA, FACOEM
Adam L. Seidner, MD, MPH
Tanisha K. Taylor, MD, MPH, MBA, CIME, FACP, FACOEM
This activity is designed for individuals who specialize in utilization review, the process used by employers and claims administrators to review treatment to determine if it is medically necessary.
Accreditation and AMA Credit Designation Statement
The American College of Occupational and Environmental Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The American College of Occupational and Environmental Medicine designates this enduring material for a maximum of 3.0 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.