L&I and Qualis Health
The Washington State Department of Labor and Industries (L&I) oversees the state’s workers’ compensation system. Qualis Health provides utilization review services to L&I. Qualis has been contracted by L&I with the goal of improving health and controlling costs. Qualis employs qualified healthcare professionals that work from its Seattle office to accomplish the utilization review process. According to the Qualis website, the success of the utilization review program depends on collaborate relationships between providers, L&I, and Qualis. The idea is that Qualis can make sure eligible injured workers get appropriate care where and when they need it.
According to L&I, the utilization review process compares requests for medical services (“utilization”) to treatment guidelines that are deemed appropriate for such services in order to prepare recommendation regarding authorization based on the comparison. The Utilization Review Program applies only in State Funded claims. It also applies to both physicians and facilities. The goal of the Utilization Review Program is to ensure that L&I purchases only proper and necessary care for injured workers.
The Qualis Utilization Review Program
Utilization Review through Qualis is required for all inpatient hepatizations except inpatient chemical dependency treatment and sub-acute stays. These include as skilled nursing facility states or transitional car unit stays that are not an acute care stay. Additionally, certain outpatient surgical procedures, physical therapy and occupational therapy after 24 visits, MRIs of the spine, upper and lower extremities, and brain, CT studies for headaches, and spinal injections all require Utilization Review by Qualis. Furthermore, Qualis uses L&I’s Medical Treatment Guidelines to make its decisions.
If a Medical Treatment Guideline is not available, then Qualis uses InterQual criteria. The initial Utilization review is conducted by a registered nurse or therapist and if the proposed treatment does not meet guidelines or criteria, the request is referred to a Qualis physician for review. If the reviewing physician is unable to recommend approval, then the requesting physician has an opportunity to discuss the case in a peer-to-peer review.
Once Qualis has competed the review, it sends its recommendation to the claim manager for review and issuance of a decision. It is ultimately the claim manager who must issue the final determination regarding authorization and inform the requesting provider. The Office of the Medical Director at L&I is responsible for managing the contract with Qualis and monitoring their quality of reviews. Like any decision made by L&I, if an injured worker or medical provider disagrees with the decision regarding authorization for recommended treatment, the determination may be protested or appealed.
On appeal, it is important to note that the criteria used by Qualis is not necessarily the same criterial considered by the Board or Court when determining whether a particular treatment is considered “necessary and proper” under the Industrial Insurance Act. As a result, while the Utilization Review by Qualis is tremendously important in the administrative management of claims, on appeal the criteria used by Qualis in recommending for or against authorization of a treatment is of little to no relevance.
It is always my first priority to help facilitate the submission of accurate information and medical findings to support treatment authorization under the Medical Treatment Guidelines or InterQual criteria. However, if for whatever reason the medical provider believes the recommended treatment is necessary and proper despite not aligning with the administrative criteria, I believe it is my job to present evidence in an appeal proving that the recommended treatment is, indeed, necessary and proper based upon the specific facts and circumstances of the claim at hand.