You got hurt on the job. Your doctor suggests a treatment, maybe physical therapy or even surgery. That sounds great, right? You’re getting the care you need. But then, your workers’ compensation insurer steps in and says, “Hold on. Is this treatment really necessary?”
This is where the Utilization Review (UR) comes process comes in. A Utilization Review is basically a check-up on your medical care. It’s a formal process where an impartial third party reviews your medical records and your doctor’s recommendations to decide if the care is reasonable and necessary for your injury. The insurer wants to make sure you get the right treatment, but they also want to control costs.
In a state like Pennsylvania, this process determines your health care. Since the insurer is involved, they often request the UR. If they find the care is not reasonable, they don’t have to pay the bill.
How Does the UR Process Work?
When your doctor requests treatment, the insurer sends the request to a Utilization Review Agent. This agent is a trained medical professional.
The UR process has four main steps. First, the request is filed with the appropriate state department, like the Commonwealth of Pennsylvania Department of Labor & Industry. This filing includes basic case information, medical records, and details about the treatment under review.
Second, you, the injured worker, can create a statement. This statement explains why you think the medical treatment is, or is not, reasonable and necessary. This is your chance to share your side!
Third, a medical professional reviews all the information. This reviewer must specialize in the same medical field as the treating doctor. They decide whether the treatment is reasonable and necessary.
Fourth, you receive the decision. The result is usually issued within 65 days of filing the request. If you disagree, you have the right to Petition the Department.
Types of Utilization Review
A UR can happen at three different times regarding your treatment:
- Prospective Review: This happens before you start the treatment. It’s common for big-ticket items like an MRI, specific prescription medication, or surgery. The insurer reviews the plan and objects if needed before the care is given.
- Concurrent Review: This review takes place while you are getting the treatment. You move forward with care, but if the treatment is later rejected, you might be responsible for those bills.
- Retrospective Review: This is one of the most common types. It happens after you’ve received the treatment and the insurer is “balking at paying the workers’ comp bills.” The insurer has 30 days to review a bill before they must pay, deny, or request a UR.
Key Determinations and Appeals
The review agent makes a specific determination on your case:
- Approval: They approve the treatment.
- Adverse Determination: They deny the request because they find the treatment is not medically necessary. Only a clinical peer reviewer can issue a denial based on medical reasons.
- Final Adverse Determination: A denial is upheld after an internal appeal.
- Modified Determination: They approve part of the treatment but change other parts.
- Delayed Determination: If they don’t give a decision within the required timeframe, typically five business days, it can result in an appealable denial.
If you get an Adverse Determination, you can appeal the decision. First, you file an internal appeal with the insurance company. Your doctor can submit more evidence to help your case. If the insurer still denies it, resulting in a Final Adverse Determination, you can pursue an external appeal. In a state like New York, this goes through the Department of Financial Services. An independent reviewer evaluates the case, and their decision is typically final and binding.
Get Legal Help for Your Workers’ Comp UR
Going through a utilization review can be complicated, especially when your health is on the line. You need to make sure your medical requests are properly submitted and backed up by solid evidence. If your review results in a denial, having a professional to guide you through the internal and external appeals process is extremely helpful. This is the best way to protect your rights and increase your chances of getting the care you need.
If you are experiencing a utilization review or a denial and need a workers’ comp law firm in Los Angeles, call Hinden & Breslavsky at (323) 954-1800. We can explain your rights and fight for the coverage you deserve.