Information Statement

Guidelines for Orthopaedic Utilization Review

This Information Statement was developed as an educational tool based on the opinion of the authors. It is not a product of a systematic review. Readers are encouraged to consider the information presented and reach their own conclusions.

Introduction

These Guidelines for Utilization Review are general guidelines. They have been developed for orthopaedists, who are involved in the planning, implementation and evaluation of utilization review activities.

Rationale

• Many organizations and entities are attempting to develop guidelines for reasonable utilization and quality review activities.
• Most guidelines are broad and nonspecific.
• Most guidelines excuse many current activities that might otherwise be considered inappropriate.
• The efforts of these groups vary and their outcomes are dependent, in most instances, on their own interests and needs.
• The purchaser wants accountability for value.
• The third party payer needs to control claims costs and hold the line on premiums.
• The private practitioner wants to limit cumbersome administrative factors and the administrative cost of medical practice and to be assured that review does not interfere with the ability to make wise decisions about appropriate care.
• Hospitals and large managed care organizations have their own unique problems in both their own review efforts, and in their own accountability to other organizations.

Utilization Review versus Peer Review

Both utilization review (UR) and peer review are components of a Quality Assurance Program. However, there are some general differences between the two components that should be noted when formulating UR guidelines:

• UR is typically a process of collecting and critically reviewing data on a department-by-department basis with the aim of improving patient care by increasing efficient use of resources and maintaining a ceiling on costs.
• Peer review is typically a process that evaluates an individual physician's medical treatment of at least one patient in order to assess the quality of care provided by that physician.

In the daily practice of medicine, these two processes often merge and become indistinguishable. Consequently, these guidelines are intended as general considerations for use in both peer review and UR processes.

Guidelines

Universality of Guidelines

1. Reasonable guidelines must be appropriate for and apply to all organizations and entities involved in utilization review. Some guidelines exempt HMO and other contracts, such as capitated PPOs.
   
   Standards for Reviewers
2. The training process for the first level reviewers must be standardized and written.
3. Review by an orthopaedic physician must be provided for in any disputed review process.
4. The qualifications of physician reviewers must be specified and documented.
   
   Responsibility in Care Denials
5. If care is determined to be unnecessary by the utilization review organization, that organization should be considered accountable for adverse outcomes resulting from their review denial.
6. There must be clear separation and description of claim denials related to coverage versus claim denials related to necessity and appropriateness
   
   Review Criteria
7. Review criteria and data assessment elements must be available to the provider being reviewed.
8. Criteria must be reviewed by the appropriate specialty organizations for comments. These comments must be documented for future reference in disputes or appeals.
9. Written requirements for criteria/standards must be periodically reviewed by the appropriate specialty organizations. Criteria/standards must stay current by reflecting changes in technology and new scientific information.
   
   Appeals Process
10. Due process must be observed in all actions.
11. There must be a mechanism for the appeal of a specialty review to a different specialist, or panel of specialists, for an independent review
    
    Timeliness of Review
12. The utilization review action, announcement, plan or description must identify specific written notice periods with deadlines for UR-related actions and activities, including follow up responses.
    
    Administration
13. Collection of duplicate information should be avoided.
14. Utilization review organizations must maintain reasonable office hours during which phone responses from providers and patients can be received from other time zones.
    
    Confidentiality Policy
15. Policies related to the handling of data on physicians and patients must be established to ensure confidentiality.
16. These policies must clearly define who may have access to information.
17. These policies must address the potential discoverability of this information in litigation.
    
    Patient Interface
18. There must be a clear policy regarding the amount and type of information the utilization review organization can disclose to the patient about a case after review. Generally, information regarding a review should not be disclosed at all, even to the patient concerned, until a final decision has been reached.
19. Utilization review organizations must not try to influence treatment decisions with the patient. The organization may discuss options including more cost effective treatments with the physician, who may then discuss them with the patient.
20. Patient care decisions must not be influenced by cumbersome administrative factors, such as treatment delays due to slow authorizations. The utilization review administrative requirements for the patient must be clearly justified and based on demonstrated quality improvement or cost efficiency.

© May 1992 American Academy of Orthopaedic Surgeons

This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons^®.

Information Statement 1003

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