Making Change Work: Utilization Review

Changes to one cost containment measure in 2011, Utilization Review, "UR", reflected Springfield's ongoing intent that health care providers treat reasonably. To name just one undesirable result of excessive care, its billing can make cases impossible to settle. One workers' compensation insurance carrier, Country Insurance and Financial Services, convinced that extensive care had obstructed enough negotiations, determined to innovatively apply UR.

Working with BCM Law, P.C., Country formulated an approach allowing settlement of the Comp case leaving bills for unreasonable care unpaid. As part of the accord, Country agreed to protect the injured worker if he was sued by the provider post contract approval and to afford a defense.

Two such settlements have resulted in civil lawsuits requiring County to step in for the worker. In the first, involving a claim for over $100,000.00 in fee bills, the providers have, at least at this point, dropped their attempt to collect from the worker, and in fact have voluntarily dismissed their lawsuit. The second involved a great deal less in fees but resulted in an actual hearing under the Mandatory Arbitration procedures of the Circuit Court of Cook County. After listening to the testimony of numerous witnesses, including the injured worker and personnel from the provider, the panel awarded the providers nothing, finding entirely in favor of the injured worker (and, of course, through him for Country).

BCM is proud to have been allowed to partner with Country to achieve these beneficial outcomes. As a result of Country's effort, issues of the reasonableness and necessity of treatment were addressed in a forum where the employer has impactful rights. Discovery in the civil courts shone a bright light on billing practices. Data was uncovered on how the chiropractors and doctors were financially rewarded by the providers. Additionally, the motion practice allowed in the civil courts forced the providers to see early on that both sides would be given a fair hearing and that trial by jury was a distinct possibility. Finally, in the civil courts, both sides have access to sanctions.