SMAI's dedicated team of utilization review nurses consistently provides fair and objective decisions in a prompt manner. Getting treatment approved quickly can mean the difference between an injured worker recovering on schedule and a claim that drags on — and costs more. Understanding how prior authorization works, and what MCOs are looking for, helps employers and HR teams keep claims moving in the right direction with the ultimate goal of returning the injured worker back to work as quickly and as safely as possible.
Breaking down the meaning of prior authorization:
When an injured worker needs certain medical treatments, procedures, or specialist referrals under Ohio's workers' compensation system, the MCO must review and approve that care before it is provided. This step exists to ensure the requested treatment is medically necessary, appropriate for the injury, and consistent with evidence-based guidelines. Clinical documentation is evaluated, along with the treating physician's rationale, and the pending/allowed diagnosis of the claim before issuing an approval, denial or pend of additional information is needed.
Where Delays May Come From:
Most prior authorization delays are not caused by the MCO sitting on a request — they stem from incomplete or missing clinical information submitted with the request. When a physician's office sends in a prior authorization without adequate updated, supporting documentation, the MCO must go back and request more detail which inevitably elongates the decision timeframe. Common documentation gaps include missing office notes, a lack of conservative treatment history, or no clear connection between the requested service and the allowed conditions in the claim. If a physician knows upfront what clinical information the MCO requires, submissions tend to be more complete from the start.
What Happens After a Decision Is Made:
MCOs are required to issue prior authorization decisions to parties to the claim within a defined timeframe. If the request is approved, treatment can proceed. If it is denied, the physician and the injured worker will receive a written explanation, and there is an appeal process available. If the request is pended for additional documentation, it is imperative that the requesting provider produces the necessary support to alleviate unnecessary delays in treatment.
In regards to the prior authorization process communication among all parties to the claim is vital to keep the claim momentum moving forward with the ultimate goal of efficient and safe return to work.
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Choosing Spooner MAI as your Ohio BWC Managed Care Organization costs you nothing extra — and our best practices can save you significantly while returning employees to work faster.