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Three Stages of Accreditation - Sign the agreement

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Workers' compensation organizations performing utilization review in California must be accredited by URAC as of July 1, 2018.

Overview

Workers’ Compensation coverage protects both employees and employers in the event of a workplace injury or related illness. While the long-term impact of COVID-19 on workers’ compensation claims are unknown, what remains constant is the need to ensure patient safety and quality care while containing spiraling medical costs. During these unprecedented times, the utilization management (UM) process has become even more critical.

URAC’s Workers’ Compensation Utilization Management Accreditation demonstrates your organization’s commitment to quality and adherence to nationally recognized guidelines. Your clients can be assured that your workers’ compensation program respects both patients’ and providers’ rights.

The URAC Difference

URAC’s Workers’ Compensation Utilization Management Accreditation infrastructure requires that you meet 40 specific core standards of best in class health care operations across the following areas:

  • Organizational Structure
  • Policies and Procedures
  • Regulatory Compliance
  • Delegated Functions
  • Marketing and Sales
  • Information Management
  • Quality Management
  • Staffing and Oversight
  • Consumer Rights, Safety and Satisfaction

Our three-year accreditation also includes standards for service accessibility, initial screenings, clinical review, decision timeframes, utilization policy, appeals and more.

Benefits of Accreditation

The basis of a successful UM program is to provide an independent, unbiased determination of patient medical necessity beginning with an initial clinical review, then moving to a peer clinical review if needed. The process ensures patients receive timely, effective treatment (and necessary medications) within accepted medical guidelines. Workers’ Compensation UM programs have the added complexity of the requirement to determine return-to-work readiness.

URAC’s Workers’ Compensation UM Accreditation provides a valued credential of quality that recognizes your expertise in determining care appropriateness with a focus on patient safety and recovery. Our team of experts work collaboratively with yours to achieve many benefits, such as:

  • Documenting a consistent, clinically sound review process that guides patients through all aspects of their medical care and mitigates patient safety risks such as contraindicated treatments, adverse drug interactions or inappropriate treatment
  • Implementing drug utilization management protocols to address therapeutic appropriateness, over and underutilization, dosage, duration and duplication
  • Validating compliance and adherence to applicable state and federal regulations for Workers’ Compensation programs
  • Implementing risk management oversight and review protocols that prevent, protect and manage client liabilities
  • Developing a roadmap for ongoing UM process and quality improvements that enhance care delivery, lower overall health care costs and optimize operational efficiencies

What to Expect

Within six months or less, we will collaborate with your team to create a flexible framework for continuous improvement in utilization management. While our experts define the standards of excellence for Workers’ Compensation UM programming, they do not prescribe how organizations must meet those standards.

URAC’s thorough approach stimulates innovation across the continuum of care through email, conference calls and educational webinars.

View our Workers’ Compensation Utilization Management Standards-at-a-Glance for more information.

Who May Apply

Managed care companies, health plans, health networks, case management companies, medical review companies and health care claims management companies may apply.