Thought Leadership

Learn More About What It Takes To Achieve URAC Accreditation

Posted by Genex on January 1, 2015

Genex Services is a leader in utilization review (UR) and has an advanced position to meet the requirements of California Senate Bill 1160, particularly the accreditation mandate. The administrative director of the program will implement a process to select the independent, nonprofit organization that will perform accreditation, but until that time, URAC will serve as the accrediting body.

Genex: Ahead of the Game

Genex has been accredited by URAC in Workers’ Compensation Utilization Management since 1996. To obtain this accreditation, Genex went through an in-depth and rigorous evaluation process that consisted of:

  • An examination of core standards related to organizational structure. URAC reviews corporate policies and procedures; marketing, sales and communications; technology and information systems; compliance with HIPAA privacy and security requirements; disaster recovery plans; staff qualifications and management, as well as other factors that confirm the strength and stability of an organization.
  • Remote review of documented UR policies and procedures. The application is submitted online. It shows compliance with every aspect of URAC UR standards in regards to clinical review, timeliness, credentialing and handling of appeals.
  • Onsite validation of documented practices. URAC confirms practices are in place, that they meet standards and are consistently carried out in real-life operations. Staff members are interviewed; the UR system is reviewed, as well as decisions and credentialing files.
  • Ongoing monitoring. URAC randomly selects UROs every month to undergo an ad hoc inspection. As such, Genex has established strong policies and procedures, as well as quality assurance practices to ensure policies and procedures are consistently followed.
  • Reaccreditation. Every three years, Genex re-applies for accreditation to ensure that it is complying with new and emerging standards, regulations and controls.
 

Other California UROs: Will They Make the Grade?

Since a considerable amount of time, effort and expertise is required to obtain URAC accreditation, there are concerns that many other UROs—which are currently unaccredited but serve the California WC market—will be unable to meet the accreditation requirement by the July 1, 2018 deadline. When a URO is starting from scratch, it can take a minimum of six months to a year to achieve URAC accreditation. However, many small and unsophisticated players may not have core standards in relation to their organizational structure, which may render them unable to meet URAC requirements. In other cases, UROs may not have the financial wherewithal to invest in IT infrastructure and procedural expertise to establish the comprehensive controls needed to become accredited.

As the state of California now recognizes, URAC accreditation provides a stamp of approval that a URO can perform UR based on a nationally accepted set of standards and best practices. As of January 2016, DWC reported that only 26 out of more than 60 UROs operating in California had attained URAC accreditation. A presentation by the RAND Corporation (dated 2/19/16) said that “accreditation would provide more assurance that the URO has the infrastructure and processes in place to comply with UR requirements.” Thus, insurers, employers and third-party administrators should begin to examine the UROs they work with in the California WC market to verify they have URAC accreditation or are well on their way to achieving it; otherwise, these UROs may fail to meet the requirement.

A Sophisticated Partner: Providing Quality Now and into the Future

Genex has achieved URAC accreditation for so long now that it has begun to go beyond URAC requirements to pioneer new levels of excellence and quality assurance (QA):

  • Four Levels of QA. Beyond the annual and quarterly QA reviews required by URAC, Genex performs monthly audits on a percentage of its reviews to ensure clinical correctness; and it performs a review of all cases to ensure they follow treatment guidelines according to their jurisdictions and that they address all questions posed in the review.
  • UR QA Committee. This committee meets at a minimum on a quarterly basis, but more frequently when needed. It discusses quality issues, ongoing performance and adherence to new state UR laws. In this way, Genex is prepared to address new legislation, such as SB 1160, as soon as it is enacted.
  • Sophisticated UR Technology. This Software-as-a-Service (SaaS) platform allows Genex customers to bring sound medical strategy to every request for treatment. This platform leverages evidence-based guidelines to automate decisions. It improves the consistency and quality of decision-making, as well as the delivery of appropriate care to injured workers.

Pioneering new standards of quality is part of Genex’s strategy to bring together the heart and science of medical management. By utilizing highly-specialized technology, physician expertise and evidence-based guidelines on every claim, Genex ensures injured workers receive appropriate care at the right time and in the right way.

Accreditation requirements may continue to evolve, based on the direction of the soon-to-beappointed administrative director. However, the advanced strategies that Genex has put in place position it to meet the ongoing needs of the California WC market, as well as the new and evolving requirements under SB 1160.

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