How a Large National Insurer Strengthened Utilization Review Oversight of FRPs in California
Clinically Nuanced Programs Need Disciplined Review
Functional restoration programs (FRPs) can help select injured employees recover and return to work. They are also high-cost, clinically nuanced programs that require disciplined utilization review (UR) to confirm the right care, at the right time, for the right duration.
Problem
18.2% FRP Approval Rate
$2M Estimated Avoided Potential Outpatient FRP Spend
A large national insurer needed a stronger approach to reviewing functional restoration program requests in California. These programs can be appropriate in the right circumstances, but inconsistent oversight can allow costly care to move forward without clear alignment to evidence-based criteria. The opportunity was clear: apply more disciplined UR so treatment matched clinical need.
A recent CWCI study provides context for why workers’ comp payers need clinical oversight and strategy around FRPs. This study shows that FRP claims averaged $234,003 and began an average of 792 days after the first medical service date, following 37 conventional physical medicine visits. Only 42.8% of FRP claims had a documented chronic pain diagnosis, even though these programs are intended for chronic pain cases.
The Solution
Enlyte applied a focused UR approach built for specialized, high-cost rehabilitation requests. Reviews centered on medical necessity, timing, treatment intensity, duration, and alignment with current guidelines.
The priority was to ensure functional restoration programs were used with precision for the right injured employee, at the right stage of recovery, and for the appropriate duration. That gave the payer a more consistent clinical review process for a treatment category that demands close oversight.
The Result
From October 2025 through March 2026, Enlyte certified 18.2% of FRP-related requests for this payer, compared with a 70% approval rate reported in the CWCI study.
Using CWCI’s average FRP outpatient treatment cost of $59,106, that difference represents an estimated $2 million in avoided potential outpatient FRP spend. More importantly, the payer gained tighter control over a high-cost treatment category and stronger alignment between requests and evidence-based criteria.
When functional restoration programs are clinically appropriate, they can play an important role in recovery. Strong UR helps you apply that care more consistently, contain high-cost requests, and keep treatment aligned with evidence-based guidelines.