First off, the Tennessee WC Education Conference is next week in Murfreesboro.? I’ll be part of a panel discussing UR best practices.
At the 6/6/2023 Medical Advisory Committee meeting, UR stats comparing appeal cases from a single quarter in each of the past 4 years (Non-Covid) were released.? See below.
- Total UR appeal accounts were 36% lower in Q1 2023 than Q4 2018
- Invasive procedures make up the majority of appeals - ~50%
- ~60% of pain related invasive procedures were upheld on appeal with a low of 55% in 2018 to a high of 68% in 2019
- Opioid appeal cases are less common now vs. 2018 - likely due to decreased prescribing patterns
- Appeal overturns are higher for opioid cases as most involve “more than one medication where upholding the denial would possibly cause potential medical problems.”
- Applicant attorneys are now filing for appeals more than providers
- Be sure invasive procedures are being looked at closely by UR
- If guidelines can’t approve from the records - get more information from the provider and obtain peer discussion.
- Limit UR on older opioid claims - they will likely get overturned on appeal
If you’re at the conference next week, be sure to say hello!
