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Utilization Review


Fundamental Value

Utilization Review (UR) is critical component inside of any payer's medical management program. Through a structured review process performed by medical professionals, it helps to prevent inappropriate and unnecessary medical care that often leads to extended claim life and undesired outcomes. However, the highly variable rule sets and jurisdictional fragmentation can create programs that are out of compliance and don’t maximize the benefits of the service.

Because Arbicare is 100% focused on Utilization Review inside of workers’ compensation, we are uniquely positioned to provide a jurisdictionally specific implementation, process improvements, expedited approval of appropriate care, and ongoing training to ensure that best practices in Utilization Review become an ingrained skillset inside of your medical management process.

Arbicare's Comparative Benefits:

At Arbicare, we recognize and believe that the unique circumstances for each payer warrant a customized approach that is specific to each organization. We approach each implementation as an opportunity to listen and observe, thus allowing us to collaborate with our clients on the solution that works best for you - not what's easiest.


PharmUR

The King v. CompPartners case in California was a sigh of relief for most UR companies in workers' compensation. For Arbicare, it was a call to action. Injured workers need proper warning. Providers need education. Payers need to reduce risk related to discontinuation of certain medications. PharmUR considers each party and provides patient specific weaning criteria inside the UR decision – all done within the confines of the regulatory timeframe.

UR Summary

UR determinations are historically not user friendly. They are filled with pages of detail listing extensive regulatory requirements – most of which aren't important to a claims handler and obfuscate interpretation of the outcome. Arbicare's UR Summary is a single page document constructed specifically for the claims handler. It contains exactly the information he/she needs from the UR decision to take the next step in administering the claim. Quite simply, the UR Summary is our way of improving the user experience and better serving the claim administrator.

Compliance/Regulatory Guidance

Each of our clients receives a jurisdictionally-specific implementation based on geographical footprint, existing resources, and the claims management philosophy instilled by your leadership team. Additionally, as new regulations are introduced (e.g. state drug formularies), you will be educated on the ramifications and provided a recommended action plan to becoming compliant with the new rules and maximizing the benefits associated with the changes.

Nationwide Coverage

Any jurisdiction, any speciality, any request - we have you covered.

Expedited Treatment Approval

Through our technology platform and fully dedicated UR team, we will provide near instant treatment approvals for medical care that aligns with evidence based guidelines. This allows patients to receive quality care immediately and treating providers to treat their patients without delay.

Dedicated Client Advocate

Client service is something you should expect from any managed care partner. At Arbicare, each client has direct access to senior leadership along with a highly educated and focused point of contact ready and able to answer your questions and make requested adjustments without delay.

Actionable Data Analytics

The data collected from your UR program has hidden insight that can better inform your future medical management decisions. We will uncover the hidden trends and produce analysis and recommendations that will strengthen your UR decision making confidence and advance your medical management programs.

Litigation Support

Our goal and entire program vision is to prevent litigation to every extent possible. Where that isn’t possible and additional support from our physician reviewers is necessary, we will coordinate schedules, depositions, and any additional requirements necessary as set forth by our client and defense counsel.

Network Integration

When UR decisions are made, we will work directly with our client’s network partners to ensure that clinical decisions are reliably informing each component of the managed care process.  Our only incentive is to make certain that medically inappropriate care isn’t unintentionally provided, enabled, and paid for.


Program Overview Statistics

Discussion Rate
41%
ROI
$3.45 : $1
On Time %
99.37%
Appeal Rate
4.96%
Turnaround Time
2 business days

Client Service Statistics

Avg. Confirmation of Referral Timing
2.5 Minutes
Phone call answer percentage
96%
Avg. time to resolve an issue
1.25 Hours
Avg. time to implement custom changes
1 business day

Employees who are valued during difficult times are employees who recover

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