The Workers’ Compensation Research Institute found wide differences in state’s workers’ compensation treatment guidelines and how they are enforced. Their report, titled “State Policies on Treatment Guidelines and Utilization Management: A National Inventory” describes patterns that are consistent with several states and policy variables that may influence compliance with the state’s guidelines. It is an inventory of medical treatment guidelines and system features that help enforce compliance with medical treatment guidelines across states.

There are 23 states that have workers’ comp medical treatment guidelines. The study sought to look at how guidelines compare based on their level of restrictiveness and clarity/ease of use. They also looked at how statutes and regulations address utilization review and dispute resolution, and how guidelines are used at various stages in the process. The study did not look at whether the state’s guidelines were based on evidence-based criteria.

Colorado and Washington developed their own guidelines and other states adopted either all or part of the American College of Occupational and Environmental Medicine or Official Disability Guidelines. The researchers looked at low-back guidelines to compare the state guidelines. In some states specific procedures are tied to objective guidelines, while others may have care inconsistencies. Some require guidelines be used for prior authorization, but providers may not be held accountable and disputes go to a legal system rather than another form of review.

Utilization review uses different standards, some states require that their medical treatment guidelines are the lone standard when it comes to UR but others use the guidelines for both UR and dispute resolution. Colorado uses a mandatory clinical standard for UR and dispute resolution. Some states penalize payors who do not adhere to their guidelines and UR. In Maine, Minnesota, and Ohio, payors who do not comply might have their participation in the state’s workers’ compensation system revoked.

WCRI hopes the results help policymakers and stakeholders learn about their current policy and identify areas to improve the delivery of medical care for workers.

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