DE OWC Clarifies Peer To Peer Conversations


Wilmington, DE - In August, the Office of Workers' Compensation (OWC) added peer-to-peer conversations to the UR process in the DE Workers' Compensation Health Care Payment System (HCPS).  The OWC medical component received reports from our UR contractors and the Health Care Advisory Panel (HCAP) that some certified health care providers' choose not to engage in the peer-to-peer conversation when the reviewer calls the office.  In many cases, this aversion to the peer-to-peer conversation began prior to the new HCPS, perhaps to avoid he said/she said contradictions.  Although nothing requires the certified provider to take advantage of this opportunity, the OWC added the peer-to-peer conversation to benefit the provider.  The “conversation” gives the treating provider an opportunity to specify the section(s) of the health care practice guidelines used to treat the injured worker prior to the like-specialist reviewer finalizing a non-certified determination.  Once the reviewer issues a non-certified determination, a party's only recourse is a lengthy, expensive UR appeal process that involves filing a de novo petition with the Industrial Accident Board, pursuant to  19 Del.C. §2322F(j).  

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