Let’s Talk: A More Enlightened Approach to Utilization Review

                               PRIUM's General Counsel fielded an irate call this week from a plaintiff's attorney in California. The attorney was upset that we had attempted to have a PRIUM physician discuss the care of his client with the client's treating physician. "There's a UR process, you know," he said.

Right. Utilization Review. That potentially contentious and often antagonistic process by which non-certifications are issued... and then, for complex treatment like chronic opioid therapy, often ignored by adjusters either too busy or too frightened to put their proverbial foot down. The UR process has it's place, but we can do better.

Once it was explained to this attorney that PRIUM (more accurately, our customer, a CA-based TPA) was actually trying to avoid engaging the UR process and was instead attempting to engage the treating physician in a collegial conversation about current treatment, expectations going forward, MTUS guidelines, and his overall goals for the patient... well, he thought that actually sounded like a good idea. When it was further explained that when the drug regimen of his client was rationalized, settlement might be a real possibility, he got even more excited. The employer had zero interest in settlement involving hundreds of thousands in drug spend, but given some time, some engagement with the treater, and some cooperation on weaning and discontinuing medically unnecessary drugs, settlement might be possible.

PRIUM doesn't hesitate to engage the UR process in cases where doctors are unwillingly to talk with us or to respond to evidence-based medicine. And we're really quite good at it. But that is not our first line intervention strategy.

Before you rush into UR, stop and think about the potential value of "let's talk..."


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