NEW TOOL ADDED TO ODG TO FACILITATE UTILIZATION REVIEW

Encinitas, CA – Work Loss Data Institute announces a new tool in Official Disability Guidelinesä (ODGä) called “ODG Treatment UR Advisor” to provide guidance in approving medical treatments used in workers’ compensation.

This utilization review (UR) advisor uses a combination of diagnosis code and procedure code to provide evidence-based recommendations sourced from the ODG treatment guidelines combined with actual outcome data.  With this information combined and presented concisely in one place, ODG users can efficiently decide to approve or deny medical treatments that may require preauthorization, that may be in a proposed treatment plan, or that have been selected for utilization management or review.

This new tool has been integrated into the Return-To-Work Section of ODG, which is organized by ICD9 diagnosis code. Beneath the guidelines for disability duration and return-to-work, three links are now provided into the treatment guidelines: (1) the “ODG Treatment Procedure Summary,” links each entry to the most important section in the treatment guidelines, summarizing the latest medical evidence for every treatment and diagnostic procedure; (2) the “ODG Treatment Contents,” links to the Contents page of the treatment guidelines; and now (3) the “ODG Treatment UR Advisor,” the new tool to facilitate utilization review.  This latter tool uses the procedure code, which is generally required from a provider in order to receive payment, to access the recommendations.  With these reimbursement codes (combined diagnosis and procedure codes), ODG users can access specific recommendations that are supported by the studies summarized, rated, and referenced in ODG Treatment in Workers’ Comp, combined with actual outcome data from the ODG workers’ compensation claims data base, representing over 2 million claims, covering almost 50 million paid invoices on medical encounters for those claims.  In addition to use by payors doing utilization review, doctors and other providers may also use this new section for treatment planning.

According to Phil Denniston, president of Work Loss Data Institute: “The primary purpose of the ODG Treatment UR Advisor is to facilitate early access to the right treatment for injured workers. At this point almost every major workers’ comp insurance company in North America is using ODG for utilization review in workers’ comp, but there are many treatments, diagnostic tests, and provider visits where the best thing the insurance reviewer can do is get out of the way and let the doctors do their job of getting the patient better. The UR Advisor lets them do that, and also frees up the reviewers’ time to handle the more complex situations where their education and experience can be used to best advantage.”

Within the list of procedure codes in the ODG Treatment UR Advisor for each diagnosis code, there are many medical codes that are lacking the support of quality medical studies, but based on actual claims data, these codes are very common for the diagnosis being reviewed, their outcomes are good, and the total costs are not excessive. Examples may include additional office visits for other specialist opinions, relatively minor laboratory tests when the treating doctor suspects another diagnosis, simple repairs of superficial wounds when the diagnosis is an open wound, etc. These are cases where there should be no delay in treatment just because a reviewer cannot find the procedure in the treatment guidelines.  

This new tool is only available in the Web version of ODG, and will not be available in the hard-copy books. The entries in the ODG Treatment UR Advisor are based on the ODG Crosswalk file, which has been available for data integration into claims systems, but the codes in the ODG Treatment UR Advisor include only a small subset of the codes in the Crosswalk, less than 20% overall, to allow for ease of use on the Web.

Evidence-based, independent and easy to use, the complete ODG Treatment in Workers’ Comp is available for $325 on the Web or in textbook format, with multi-user discounts available. Official Disability Guidelines (without the treatment guidelines) is available alone at the cost of $195.  Raw data files for benchmarking claims data or integration with internal software applications are also available. Contact WLDI for licensing fees.

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Copyright © 2009 Work Loss Data Institute
Last modified: February 26, 2009