Utilization Review

Approvals when appropriate and denials that stick.”

OMCA Philosophy
Utilization Review (UR) involves screening certain proposed medical procedures and pharmaceuticals to determine if they are medically necessary and appropriate based upon established review criteria. This includes prior authorization for hospital admissions, all surgeries and diagnostic studies, and concurrent stay review, ensuring that injured workers are discharged from the hospital when the level of service they are receiving no longer requires inpatient care.

At OMCA, UR is not merely an administrative function. Our nurse case managers and physician advisors utilize the latest evidence-based criteria in evaluating each UR submission.

As a member of a select fraternity that has chosen to be URAC accredited for Workers’ Compensation Utilization Management, OMCA has made the investment to ensure that appropriate requests are promptly approved while denials are thoroughly researched and scientifically supported. Several of our physician advisors are authors of Workers’ Compensation clinical guidelines and recognized nationally as leaders in their fields of medicine. URAC accreditation lets clients know that OMCA adheres to the highest industry standards as we help payors effectively control their medical costs and case reserves.

Peer Review
In addition to determining medical necessity, OMCA nurse case managers are specifically trained and uniquely skilled to identify questions of relatedness and compensability. Upon consultation with our client, a Peer Review may be undertaken before the UR process continues. OMCA will provide a specialty-match reviewer who uses the latest scientific evidence to make the correct determination regarding relatedness in these questionable situations.

Review Panel
At OMCA, we have spent the last 30 years developing a panel of board certified physicians whose credentials, experience and reputation (with regulators and employers alike) are second-to-none. Whether local or national, our physician advisors are committed to applying the best medical evidence to control costs and manage reserves.

OMCA specialty-match reviewers are available nationwide in all medical areas including:

  • Addiction Medicine
  • Anesthesiology
  • General Surgery
  • Hand Surgery
  • Neurology
  • Neurosurgery
  • Occupational Medicine
  • Orthopaedic Surgery
  • Pain Medicine
  • Physical Medicine & Rehabilitation
  • Psychiatry
  • Toxicology
  • Urology
For more information about Workers’ Compensation services, contact OMCA at (800) 633-5960 or info@omca.biz. Referrals may be sent to ur@omca.biz.