Utilization Review

“Approvals when appropriate and Denials that stick”

OMCA Philosophy

Utilization Review (UR) involves screening certain proposed medical procedures to determine if they are reasonably related, 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 to insure that patients 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 registered nurses and physician reviewers utilize the latest evidence based criteria in evaluating each UR submission. UR decisions made by less qualified staff results in unnecessary procedures and denials that don’t stick.

URAC

As a member of a select fraternity that has chosen to be URAC accredited for workers’ compensation utilization management, we have made the investment to ensure that appropriate requests are immediately approved while denials are thoroughly researched and scientifically supported. Many 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 we will adhere to the highest industry standards as we help payers effectively control their medical costs and case reserves.

Peer Review

In addition to determining medical necessity, OMCA registered nurse case managers are specifically trained and uniquely skilled to identify questions of relatedness and compensability. Upon consultation with our client, a specialty match Peer Review may be undertaken before the UR process continues. Our Board Certified Physician Advisor Panel will provide a peer match physician who uses the latest scientific evidence to achieve the best outcome in these questionable situations.

Enhanced Utilization Review

Many clients request OMCA to go further than the traditional UR function. Enhanced UR calls for the OMCA Registered Nurse Case Manager to closely monitor the injured employee for 3 to 6 months after a surgical procedure. Enhanced UR involves the following areas and helps ensure the best outcome and the quickest return to work.

Verify the specifics of an effective Treatment Plan
Assist and verify rehab progress
Pharmaceutical Compliance
Monitor Outcome Objectives
Suggest changes to treatment plan, if needed
Enhance Patient Accountability

Accessing OMCA’s UR Services

OMCA provides UR services to carriers, third party administrators, self funded employers and excess/ reinsurance carriers. These services are provided nationwide and can be acquired on a stand alone basis or in conjunction with other OMCA programs.

Contact Rosalie Faris, RN, BSN, CCM, COHN-S for further questions at rosalie.faris@omca.biz

From our Clients & Colleagues

Angela Harris Self-funded Employer

"OMCA is easy to communicate and work with. I don’t feel like a number when I inquire about a claim. They know the case and employee I am speaking of immediately. You really feel like you’re receiving personalized service."