When we have a standard of care that is published, when all the players in the game know all the rules of the game, everyone wins. If a practitioner chooses to step outside the rules, he then knows why a claim has been questioned. The cornerstone of a managed workers' compensation program is the protocols or standards of care. These standards would be used to review cases and determine the justification for the diagnosis and treatment. There is a tremendous variation in practice patterns in the workers' compensation environment.
Variation is an a priori definition of poor quality.
A UMO should have the expertise to clinically discuss the most appropriate tests and procedures if those suggested by the attending physician are not the most current or the most efficient. Once certification has been granted, there should be frequent review of the need for further care, further tests, or further procedures. Those same averaged programs may also permit non-causally related procedures through lack of attention of the unique workers' compensation needs. All chiropractic review programs should have a structured quality assurance and quality improvement program in place that monitors record timeliness and completeness, as well as the clinical quality of decisions made by staff case assistants, nurse reviewers, chiropractic physician advisors, and network physicians. Regular training sessions should be held to assure that the reviewers have the latest and most accurate information on which to base their decisions.