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A utilization review is a process that is used to determine whether a particular medical provider or the care that he or she is providing is reasonable and necessary under the circumstances.

In Pennsylvania, an injured workers’ health care is decided in part by the employer and in part by the injured worker. Both workers and their employers contribute to the decision of which healthcare provider to use. However, not everyone will always agree on the type of care that a provider wants to give a worker.

In some situations, the employee may feel certain care is appropriate while their employer or the employer’s insurance company disagrees.

In other circumstances, the opposite may be true—the insurance company would like to see a certain type of care provided, but the worker disagrees. Under either of these circumstances, any party can request a “utilization review.”

What Does a Utilization Review Do?

A utilization review (“UR”) asks an impartial third party to review your medical records and the recommendations made by your provider to determine whether they are reasonable recommendations.

As part of that process, they also consider a statement provided from you describing your condition and, if applicable, why you feel that the recommended treatment is not reasonable or necessary.

How Does the Workers’ Compensation Utilization Review Process Work?

These are the four steps to the worker’s comp utilization review process:

File the Utilization Review Request

You or the employer’s insurance company will file a UR request with the Commonwealth of Pennsylvania Department of Labor & Industry using a specific form provided by the Department.

The application will include:

• Basic information about your case
• Data regarding the medical provider that will be reviewed
• Information about the treatment under view
• Billing dates (if the review is retrospective)
• Payments that are pending the decision
• Medical records and other related information regarding the injured worker’s situation

Create a Statement to Provide to the Reviewer

Employees can also create a statement to send along with the request for review. That statement should explain why you think the medical treatment is reasonable and necessary, or not.

If an insurance company requests the UR in your workers’ compensation case, then you will receive a “Notice to Injured Worker” that explains what the insurance company is seeking.

Review by the Medical Professional

Once all of the information is submitted, it is sent to a medical professional whose specialty matches with whatever recommended treatment is at issue. The professional will review the record and decide whether the treatment is reasonable and necessary.

The result of the review is generally issued within 65 days after the request is filed.

Receive and Review the Decision

Once a decision is made, you should also get a mailed notification of that decision as well. If you disagree, you have the right to Petition to the Department. In some cases, the decision will be no in part, but also yes in part.

The decision should specifically state which parts of the treatment are reasonable and necessary if everything is not considered reasonable.

When Does a Workers’ Comp Utilization Review Take Place?

In most cases, it is the employer or its insurance company that requests a utilization review. They do this because a treatment or care program has been recommended that they do not necessarily agree with or think is a good idea for your situation.

If they are successful in getting a determination that the care is not reasonable or necessary, then the insurance company can save money by denying the request for care.

Generally, there are three types of utilization review under Pennsylvania workers’ compensation law. The process will vary depending on how the review is requested.

Prospective Review

In this type of utilization review, a provider has recommended treatment, but the treatment has not been performed yet. This type of review often happens with more intensive testing or surgery.

Some common examples include:

• An MRI
• Specific kinds of prescription medication
• Surgery
• Unique or new medical treatment or care
• Follow up care, such as physical therapy or cognitive therapy

Under any of these examples, an insurance company would likely be contacted before starting treatment or testing. This contact allows them to examine the reasonableness of the treatment and object to it if necessary.

Concurrent Review

A concurrent utilization review happens at the same time that you are getting treatment. On the one hand, it is nice that you can move forward with treatment even while it is being reviewed.

On the other hand, it is possible that the treatment may be rejected, and the insurance company avoids having to pay bills that you may need to cover on your own.

Retrospective Review

If you have already gone through the treatment and the insurance company is balking at paying the workers’ comp bills, they may request a utilization review at that point. This is one of the most common times that a utilization review occurs, unfortunately.

When an insurance company receives a workers’ compensation bill, it has 30 days to review the bill and decide whether it will pay it, deny it, or request a utilization review. If the utilization review determines that the care was not reasonable and necessary, then the insurance company does not have to pay the bill.

FAQs Regarding Utilization Reviews in Work Comp

Here are common questions and answers related to utilization reviews:

What is the Main Reason for a Utilization Review?

In most cases, insurance companies request a UR because they do not want to pay for the treatment recommended by your treating doctor.

Is a Utilization Review the Same Thing as an IME?

No. An Independent Medical Examination provides opinions about your current physical and/or mental condition to give an impairment rating. Although both medical professionals will review your medical records, the goal in an IME is very different compared to a UR.

Will Other Bills Still be Paid During the UR?

The only bills affected by the UR are the ones concerning the specific provider or treatment under view. The insurance company should still pay for everything else.

Will Further Treatment Be Paid for by the Insurance Company?

It depends. In some situations, if you do not need the treatment under review, then you may not have any additional medical bills. If that is not the case, however, the insurance company should still pay for other types of treatment that are not under review.

Will I Still Be Able to Get Prescription Medications During the Review?

Maybe. Some pharmacies will put the medication on hold during the review, while others will still provide prescriptions as normal. Talk to your specific pharmacist about their policies.

Any More Questions About Workers’ Compensation Utilization Reviews? We Can Help!

The workers’ comp attorneys at Krasno Krasno & Onwudinjo can help you work through the entire Utilization Review process. We can assist with writing a compelling statement, the appeal process, and more.

Call today to set up an appointment to speak with a member of our team or use the form to your left to schedule your free case evaluation.