Occupational Medical Utilization Review Services for Workers’ Compensation
For Workers’ Compensation – Occucare Corporate Medical Direction
Physician-led prior authorization and workers’ compensation cost control – for TPAs, claims administrators, and self-insured employers who cannot afford reversals at independent review (IRO in Texas, IMR in California)
Clinic Hours
- Monday - Friday 7:30 AM - 4:30 PM CST
- +1 713 802 0801
What is occupational medical utilization review?
Occucare’s board-certified physician reviewers apply evidence-based treatment guidelines to every Request for Authorization, delivering defensible, timely decisions that contain claim costs and accelerate Return-to-Work outcomes for claims administrators, TPAs, and self-insured employers.
All Determinations Issued by Board-Certified Occupational Medicine Physicians
Serving TPAs, Self-Insured Employers & Claims Administrators
Physician Authority on Every Denial
ACOEM, ODG, MCG & InterQual Applied
At Occucare, Utilization Review is not an outsourced software function. It is an integrated component of our Corporate Medical Direction framework, governed by licensed physicians who hold accountability for every decision, every denial, and every peer-to-peer review.
Our physician-led review methodology
Every RFA routed to Occucare undergoes structured clinical evaluation against the industry’s most rigorous treatment guidelines. Our reviewing physicians assess medical records, treatment history, and Workplace Injury Care context before issuing any determination.
Guideline | Application |
ACOEM | American College of Occupational and Environmental Medicine, primary framework for Occupational Health injuries. |
ODG | Official Disability Guidelines, enforced to cap excessive therapy, imaging, and surgical requests. |
MCG | Milliman Care Guidelines, applied for complex admissions and high-cost interventions. |
InterQual | Used for surgical procedures, inpatient stays, and specialist referrals requiring additional clinical scrutiny. |
Decision outcomes
Occucare physicians issue one of three standardized determinations:
Approve
treatment meets evidence-based medical necessity criteria
Modify
adjustments required to align care with applicable guidelines
Deny
treatment not supported by current clinical evidence; documentation provided for IRO/IMR defense
Comprehensive Review Cycles
Prospective Review
Before care begins
Prior authorization confirms medical necessity before treatment begins, stopping unnecessary interventions at the earliest possible point.
Concurrent Review
During active treatment
Active monitoring of hospital stays and therapy programs ensures care progression aligns with RTW and MMI benchmarks.
Retrospective Review
After care completion
Post-treatment audits assess compliance, guideline adherence, and cost recovery on claims already closed or in dispute.
High-Cost & High-Risk Treatments We Review
Our physicians review high-cost, high-risk treatment categories across all stages of a workers’ compensation claim.
- Inpatient hospital admissions: surgical and facility stays reviewed for necessity and appropriate duration
- Diagnostic imaging: MRI and CT requests evaluated against guideline-specific criteria
- Physical and occupational therapy: program approvals with concurrent monitoring against Return to Work milestones
- Surgical procedures: prospective review to prevent premature or unsupported interventions
- Pharmacy and DME: medication regimens and equipment requests reviewed for appropriateness
- Non-emergency transport: ambulance and air transport screened for medical justification via Emergency Response.
Strategic Solutions for Claims Administrators & TPAs
Cost exposure
Controlling runaway claim costs
Standard UR nurses often function as rubber stamps for aggressive treatment plans. Occucare’s Corporate Medical Directors intervene to halt medically unsupported surgeries, cap endless physical therapy cycles, and enforce ODG and ACOEM threshold directly protecting your bottom line on every high-cost claim.
Legal defensibility
Surviving independent review challenges
Without physician-backed rationale, denials are routinely overturned at Independent Medical Review. Occucare’s determinations are issued by board-certified physicians with documented guideline citations, reducing reversal rates at independent review and claim volatility.
Duration risk
Accelerating return to work
Delays in care oversight extend disability durations and inflate total claim costs. Our concurrent review ensures treatment progression tracks against established Return To Work and MMI benchmarks not the provider’s billing calendar.
Operational burden
Reducing administrative overhead
Occucare’s standardized RFA workflows, automated routing, and audit-ready documentation reduce the operational load on TPA staff and claims administrators, freeing your team to focus on complex case management.
Medical Utilization Review in Occupational Health for Self-Insured Employers
For self-insured construction and industrial employers, every unreviewed MRI, open-ended therapy authorization or premature surgical referral is paid directly from the company’s own funds. Occucare’s physician reviewers evaluate each request against ACOEM and ODG before it is approved, tie therapy to return-to-work milestones, and document every decision so it holds up at independent review. Because the same Corporate Medical Direction team oversees workplace injury case management, review decisions and RTW planning move together instead of in separate silos.
Integrated corporate medical direction
Utilization Review delivers maximum value when it operates as part of a unified medical governance strategy. At Occucare, our Utilization Review physicians do not function in isolation, they are embedded within a broader Corporate Medical Direction framework.
While our consulting team designs your occupational health and safety protocols and our clinic oversight team manages provider relationships, our UR physician reviewers serve as your financial and clinical auditors, identifying unnecessary care before it compounds into long-term claim liability.
UR vs. case management vs. IMR
Understanding how Occucare’s UR service fits within the broader workers’ compensation ecosystem:
| Function | Utilization Review (Occucare) | Case Management | Independent Review (IRO / IMR). |
| Purpose | Medical necessity evaluation | Care coordination | Appeal resolution |
| Timing | Before, during, and after care | Ongoing | Post-denial |
| Decision authority | Occucare board-certified physician | Non-decision support | External reviewer |
| Primary value | Cost containment + legal defense | Recovery coordination | Dispute resolution |
Occupational Utilization Review vs. Emergency Case Utilization Review
Occupational utilization review services cover the full life of a workers’ compensation claim: prospective, concurrent and retrospective review of therapy, imaging, surgery and pharmacy requests. When a worker is injured in a remote field or offshore location and needs a same-hour decision on transport or admission, Occucare’s emergency case utilization review applies the same physician authority in real time.
Industries We Serve
Frequently Asked Questions
An RFA is the formal submission from a treating provider requesting approval for a specific Workplace Injury Treatment under workers' compensation. Occucare physicians evaluate each RFA against applicable evidence-based guidelines before issuing a determination.
The injured worker or provider may initiate an Independent Medical Review (IMR). Because Occucare determinations are physician-authored with documented guideline citations, they are specifically structured to withstand IMR scrutiny.
Turnaround times are governed by state-specific regulatory deadlines. Occucare's workflow infrastructure is built for compliance with these timelines across all Locations we serve.
All modification and denial decisions are issued by licensed, board-certified Corporate Medical Direction physicians. Clinical staff support the intake and documentation process, but medical authority sits with our physician reviewers at all times.
Our reviewers apply ACOEM, ODG, MCG, and InterQual criteria selected based on treatment type, jurisdiction, and clinical complexity of the case.
Work with Occucare's Corporate Medical Directors
Control costs, reduce IMR exposure, and improve return-to-work outcomes across your workers’ compensation program.