Provider Utilization Review (UR) activities are supported in the AdjusterPortal through integration of the Evidence-Based Medicine (EBM) tools ODG Treatment and UR Advisor.
What is the ODG Treatment Feature?
Official Disability Guidelines (ODG), published by the Work Loss Data Institute (WLDI), is a nationally-respected resource for EBM. It provides up-to-date, evidence-based disability duration guidelines and benchmarking data covering every reportable condition for non-occupational disability cases (ODG) and workers’ compensation cases (ODG Treatment). Published annually, ODG Treatment is the result of a comprehensive ongoing review of existing scientific evidence including over 10 million cases from workers’ compensation insurance carriers.
ODG Treatment may improve the UR process in workers' compensation cases by supporting the evaluation of specified courses of proposed medical treatment.
What is the UR Advisor?
Complementing ODG Treatment is the UR Advisor. UR Advisor provides raw data for every possible ICD9 diagnosis code/CPT procedure code combination seen in workers’ compensation cases (currently over 200,000 records) and related frequency, number of visits, and recommendations from ODG Treatment.
How are ODG Treatment/UR Advisor integrated into StrataWare?
License to the ODG Treatment/UR Advisor tools is a value-added resource available in StrataWare. When making bill approvals or denials, ODG recommendations are presented via the UR Advisor Bill Review Payment Flags (color codes). The colors codes denote one of four levels of compliance for a bill. When editing or reviewing service lines, specific UR information is presented to the adjuster such as number of visits, medical costs, return-to-work summaries, and other data. The information is hyper-linked to the specific ODG Treatment guidelines. The complete ODG Treatment resource is available to adjusters during bill editing for reference on an injury, diagnosis, treatment plan, and costs.
How does ODG benefit Bill Review Adjusters?
Independent studies show ODG to be an effective resource for utilization management, which can optimize results in workers’ compensation cases. ODG may also help to minimize disputes between physicians and carriers due to its standardized criteria for prescribing medical treatment and disability duration guidelines, specific utilization review, return-to-work guidelines, and cost containment.
ODG can increase efficiencies by providing a centralized support resource for adjusters and nurse case managers to view medical evidence regarding a medical treatment.
Various states such as California, Kansas, Missouri, North Dakota, and Texas have either adopted or mandated ODG as the primary standard of reference for EBM in treating injured workers. More states are expected to do so as well. Carriers are not liable for treatment provided in excess of ODG guidelines unless pre-authorized or provided in a medical emergency.
Legal Disclaimer: StrataCare does not practice evidence based medicine, perform utilization review, or make decisions regarding treatment plans. The ODG is a third party resource published by the WLDI and is licensed through StrataCare. The ODG Library is intended for use as a resource tool and is ideally utilized as one component of a comprehensive plan of care. Medical treatment and care decisions remain the responsibility of the licensed practitioner and the care management team, which may include the adjustor and case management staff. For more information on the ODG, please visit Work Loss Data Institute’s website at www.worklossdata.com
