As the Medical Director of a physician-driven utilization review organization, I can attest our reviewers understand the business of medicine and how the virus has impacted the utilization review process in workers’ compensation.

In the process, the reviewers can concentrate on the issue to be discussed. This article focuses on the gap of elective procedures resulting in fewer hospital stays, surgical center use and the income deficiency identified by surgical specialties.

As a Medical Director dealing with utilization review during this “reopening phase,” I have frequently seen an increased use of surgery centers for elective procedures. Because the financial gap created by the pandemic has impacted the practice of the surgical specialties and narrowed their scope to emergency procedures only, providers requesting procedures tend to “overstate” the case for procedures to be performed.

Now, as the restrictions have relaxed and the “flood gates” are open, the surgical specialties are looking to complete their delayed elective procedures. Although there is no problem with this as most elective procedures have been medically necessary, the continued delay has been a burden on the workers’ compensation system because of the rule of presumption exercised by many states associated with disability time resulting in the “no work” mentality.
From the standpoint of the utilization reviewer, the request for the procedures must be viewed extremely carefully and focused on details of the history, examination and testing prior to the decision for any surgical procedures to be certified. Theoretically, the reviewer always does this, but I am suggesting a second look at decisions for surgery when other methods of treatment are or can be available. Yes, guidelines are viewed and used as a tool for decision making, but my concern is that the history might be somewhat exaggerated to fit the need. It is difficult for reviewers to discern how much is real and how much is not because the reviewer does not see the patient and must rely on what is written and/or the discussion with the requesting provider.
I do not believe that there is any real conscious motivation by physicians to do any unnecessary procedures, but providers in surgical specialties are faced with the dilemma of office management and cost issues for operation of their facilities/offices. There has been a dry spell in these specialties, and there has been a greater number of providers retiring or leaving their practices because of the diminished fiscal return.

Those that have and will survive may tend to look at the need to accelerate the surgical schedule.

Reviewers must be extra discerning in the evaluation and decision to certify surgery. Make an extra effort to discuss the case with the requesting provider, and make certain that all avenues of conservative care are being tried or have been tried prior to the certification of an elective procedure.

This article is focused on the reviewer’s responsibility in being extremely careful and aware of his/her decision making.