A Guide to Utilization Reviews for Pennsylvania Workers’ Compensation Cases

You learn that your medical treatment is under utilization review. What exactly does that mean? Should you be concerned?

Pennsylvania workers’ compensation insurance companies hire adjusters to save the company money—not to help the injured workers. Insurance companies will do whatever they can to keep money in their own coffers—their concern is not to make sure that you get all of the benefits that you deserve, but to minimize their costs and maximize their profits.

What is a Utilization Review?

Utilization Review is a method that workers’ compensation insurance companies often employ in Pennsylvania to deny you needed medical treatment. Even after you engage an attorney that successfully litigates your case and obtains a favorable result granting indemnity and medical expenses, the insurance company can then file a Utilization Review Request claiming that your medical treatment is not “reasonable and necessary.” It’s crucial that you have an experienced workers’ compensation attorney in Pennsylvania on your side to navigate this potentially complex process.

You may be happy with your medical provider and the care that he or she is providing to you, but the insurance company may feel that your treatment is costing them too much money. Utilization Review [commonly abbreviated UR] is the process used to challenge whether the medical treatment that an injured worker is receiving is reasonable and necessary.

Utilization Review Process

Ordinarily, the UR Request is filed by the insurance carrier, although injured workers are free to file such a petition. When a request for review is filed, the Bureau of Workers’ Compensation assigns the review to a Utilization Review Organization [commonly abbreviated URO]. The URO then attempts to gather all the medical records related to the course of treatment. For UR purposes, it is assumed that the treatment is causally related to the workers’ compensation injury—if the insurance carrier wants to challenge whether the treatment is causally related, it must file a separate Review Petition with the Bureau, and that gets assigned to a workers’ compensation judge.

Who Performs the Utilization Review?

A UR must be performed by a qualified medical specialist with the same expertise as the medical provider whose treatment is being reviewed. For example, if the injured worker is treating with a chiropractor, another chiropractor must be assigned to review the treatment in question. If a treating doctor does not timely provide records to the URO, the treatment will be denied as not reasonable and necessary.

What Treatment is Reviewed?

A UR can review medical treatment either prospectively, concurrently, or retrospectively. The most common type of review is retrospective where the insurance company receives a bill from the medical provider where the treatment was performed. Once the bill is received in proper form, the insurance company has 30 days to either pay or deny the bill, or the alternative is to request that a UR be performed.

Will My Medical Bills Get Paid During the Utilization Review Process?

During the time that the medical treatment is in dispute, the submitted medical bills are generally not paid by the insurance company until the URO resolves the dispute. Many providers are still willing to provide treatment while the dispute is pending. Many adjusters mistakenly insist that they can refuse to pre-approve treatment because their doctor who examined the patient found that he or she had fully recovered. However, the proper procedure is for the carrier to file for UR instead of outright denying the treatment.

What Opinions Will the UR Medical Specialist Provide?

The reviewing medical specialist may find that the treatment in question is totally reasonable and necessary, partially reasonable and necessary, or totally unreasonable and unnecessary. URs can be quite complicated and directly impact the treatment that an injured worker receives, and therefore, a well-qualified Philadelphia workers’ compensation attorney is necessary to navigate through the process. It is often extremely helpful for the medical provider to speak with the reviewer to explain why the treatment is needed. Also, the injured worker can provide a written statement to the Reviewer explaining why the treatment is beneficial.

Can the Parties Appeal the Utilization Review?

If the URO finds that medical treatment is not reasonable and necessary, the employee can either accept the ruling or file a Petition to Review the UR Determination. Any party who disagrees with the findings of the UR may file a timely Petition to Review the UR to be heard and decided by a workers’ compensation judge. The provider under review will then either testify by deposition as to the treatment in question or issue a report indicating why the treatment is reasonable and necessary. Similarly, an injured worker will have the opportunity to testify regarding why the treatment provides him or her relief and to try to convince the judge that the treatment is reasonable and necessary. Treatment that does not improve a patient’s condition can still be reasonable and necessary if it provides the patient with pain relief. An experienced Pittsburgh workers’ compensation attorney will know how to properly present the case to achieve the best result for the client.

Positive Outcomes for Cases Involving a Utilization Review

Certified Pennsylvania Work Comp Specialist, Michael W. Cardamone of The Cardamone Law Firm recently won a Petition for Review of a Utilization Review for his client. The central issue in the case was whether chiropractic treatment was reasonable and necessary. In this context, the burden of proof is on the employer to establish that the challenged treatment is not reasonable and necessary. Cardamone successfully argued that the treatment helped his client to continue working  and provided functional improvement.  After all, what could be more useful than treatment allowing an injured worker to keep his or her job?

In the litigation, Cardamone presented his client’s testimony and a narrative report of the treating physician which outlined why the treatment was reasonable and necessary. The Workers’ Compensation Judge issued her Decision finding that the Employer failed to prove the chiropractic treatment was unreasonable or unnecessary. Accordingly, the Employer/Insurer has to pay for the treatment, and litigation costs were awarded.

It is important for injured workers to challenge Utilization Review Determinations that find treatment unreasonable or unnecessary. Call me if you are not already represented by a Certified PA Work Comp Lawyer, so I can challenge the Determination by filing a Petition to Review. There are strict deadlines for appealing these Determinations so be guided accordingly and act quickly.

URs can be quite complicated and can directly impact the life and well-being of the patient and a well-qualified Lancaster workers’ compensation attorney can literally be a life-saver for an injured worker.