Would you like to use your medical knowledge, earn extra income, and learn a new skill?
Independent utilization review (sometimes called “chart review”) is a great way to do all of the above, as well as explore a potential nonclinical job while you’re still in practice.
Today we’re diving in with radiologist Dr. Michelle Sterling, who is the Executive Medical Director – Clinical Quality at Medical Review Institute of America, LLC, (MRIoA). One aspect of her job is overseeing physicians who do external utilization reviews on behalf of MRIoA.
Dr. Sterling shares a lot of helpful information about doing utilization reviews and also mentions which specialties MRIoA is currently recruiting for.
How did you get started in utilization management?
I was very unhappy in my career as a radiologist and I knew I needed a change. It was important for me to use my medical degree that I had worked so hard to obtain. Also, I was frustrated with the overutilization of certain resources that I was seeing as a radiologist.
I worked with Heather to help figure out what the best path was for my future. She told me about an opening at MRIoA and I applied. That was 3 ½ years ago and I love what I do. I started out doing utilization management but have transitioned into an executive management level position and now I oversee our external physician reviewers alongside our Director of Provider Relations.
I really enjoy working with the reviewers on our specialty panel and I have learned a lot from them. We have some internal reviewers who work full time, but most of our reviewers are specialists in clinical practice who perform the external reviews as independent contractors a few hours per week.
What kind of work are the external physician reviewers doing?
In most cases they are reviewing medical and/or pharmacy claims – initial prior authorizations and appeals. These reviews fall into several different categories:
Criteria Based Reviews – making sure specific criteria for the medical plan is being met, Medical Necessity – making sure the service or drug is appropriate for the patient’s condition or Investigational and Experimental Treatments.
What is a typical day like for an external reviewer?
Our external reviewers are in active practice and spending their day as most physicians do in their busy practices. The only difference is when a patient cancels or they have a little downtime in their day, these physicians can work on reviews they have already been assigned by MRIoA.
Some reviewers like to schedule our reviews while they eat lunch, or before or after seeing patients. It is really a flexible process so that it can meet their own scheduling needs. Typically, cases have a 24 or 48-hour turnaround time, (TAT). The reviews themselves vary with some being 5 – 10 minutes, while others may take from 30 – 60 minutes or longer to complete. The reviewers work with MRIoA to find the types of reviews that fit their personality and skill set.
What do the physician reviewers most enjoy about doing this work?
The physicians enjoy knowing they’re helping patients get the appropriate care they need. Sometimes an incorrect study is ordered and the reviewer can make recommendations regarding alternatives to assist in getting the patient the proper study or treatment. They also feel the work helps them stay on top of industry standards and current literature. After residency, practice is so busy that it can be hard to keep up with the literature and advancements, and doing the reviews is a great way to stay current.
Are there any downsides to doing review work?
Sometimes you might not have enough information to make a determination; however, there are additional levels of appeals.
The peer-to-peer calls can also sometimes be stressful; however, to be honest, the vast majority of peer-to-peer calls that I have completed are positive. Depending on what the case is, you might be able to obtain additional information which could lead to the request being approved. Or there might be an alternative approach that can be taken.
Is the time frame required to complete a case a challenge for some of the reviewers?
In order to do this type of work you need to have the commitment to meet the deadlines because the TATs (turn-around-times) are regulated. The good news is you can turn your availability off at any time for things like a call day, if you’re in the OR, or during a week where you’re especially busy. When you mark yourself unavailable in our system, you won’t be contacted for reviews.
What is the compensation like?
Physician reviewers are paid on a case by case basis. Payment on each case is determined according to the complexity of the case – the more complex (and longer the case) the higher the reimbursement. Rates also vary depending on specialty.
How would a physician know if Review Work is right for them?
If you are concerned about the over-utilization of services and want patients to get appropriate but not unnecessary treatment, this could be a reason for wanting to do review work.
The extra income is a nice perk too. Trying out utilization review is also a good way to see if you might want to transition later into doing something full time in this area. It also can be a good addition to your resume.
What do you tell physicians who are reluctant to do this work because of the peer-to-peer calls?
It is rewarding when you can talk to a fellow physician and get new information about a patient that could lead to a favorable determination. While their request may not meet criteria for what they wanted, you might be able to suggest an alternative and the doctor is happy.
The reviewers become more comfortable in time with the peer-to-peers and the ability to handle challenging conversations is a good skill to have. If a physician doesn’t like any kind of conflict, then this type of work may not be a good fit.
What advice would you give someone interested in doing Review work?
If you feel you would find this type of work rewarding, try it! We don’t have minimum case volume expectations or require the external reviewers to commit to working with us for any length of time. As you are starting out, our team checks in with you frequently to see how you are doing, what you like, and talks with you about what you’re struggling with. This also helps us figure out what types of cases work best for you, which ultimately works better for us. Hopefully, you’ll enjoy the work and will want to continue.
What question do you get asked by reviewers most often?
Almost every new reviewer asks if they have to deny a certain number of reviews in order to work with MRIoA. And the answer is NO! We do not keep track of approvals versus denials for any one reviewer. The goal is and always will be to make the right determination for the patient and prescribing physician whether it is an approval or denial.
What are MRIoA’s requirements for physicians who want to do utilization review?
The physicians need to be board-certified, have an active, unrestricted license, be currently practicing a minimum of 8 hours a week, and have at least 5 years of clinical experience which can include residency.
Is specific training needed?
There is no training needed prior to beginning review work. If you are interested, you would first complete a test case. Once the test case is reviewed, there is a 45-minute training session where we go over expectations and instructions on different case types and case requirements. We also have a clinical team available for questions on cases as you are completing them.
Are you currently recruiting any physicians as independent contractors to be external reviewers?
We have physicians on our panels specializing in about 150 different specialty areas. Many of those specialty areas are currently full, but there are still a lot of areas where we are looking for new reviewers to help with our increasing volume of cases.
We are actively recruiting for:
Orthopedic Surgeons, Psychiatrists, Anesthesiologists with Pain Medicine Certification, and PM&R with Pain Medicine Certification. We are also recruiting for Internal Medicine/Occupational Medicine dual board certification specialists, Vascular Surgeons, Neuro-Ophthalmologists, and Oncologists.
Adding to our waitlist:
For now, we don’t have needs in other areas like Family Medicine, Internal Medicine, Emergency Medicine, or Pediatrics. However, we do keep waiting lists of those who are interested and can let them know when we do have needs that arise.
Who should physicians contact for more information?
They can email Medical.Opportunities@mrioa.com or call (801) 265-6427.
A big Thank You to Dr. Michelle Sterling for coming on the blog and providing all this useful information!