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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.

Awards & Recognitions

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Cardamone Law Has Negotiated Some of the Largest Workers’ Comp Settlements in Pennsylvania

$6 Million
Acted as Co-Counsel on a Case that Settled
$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$740,000
Amputation
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury
$6 Million
Acted as Co-Counsel on a Case that Settled
$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$740,000
Amputation
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury

Client Testimonials

"Without a doubt YOU are the best!!!"

"Without a doubt YOU are the best!!! Every person who is in the horrible position of being injured at work should have someone as kind, compassionate and knowledgeable as you on their side. You never once made me feel like I was one of a hundred other clients. I always knew you had my back! You answered calls and emails at all hours. You fought every fight for me so I only had to worry about getting well. Behind your nice, calm face there’s a pit bull ready to take on any employer or judge. I can never thank you enough."

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I called Shirley when I was scared and didn’t know what where my next dime was coming from after I was out with my work injury. Shirley was very kind and helpful guiding me every single step of the way. Mike was not your typical lawyer was not pushy but very responsive to all my gazillion questions. He helped me get my settlement quickly and settlement check in a very timely manner. Would recommend them to anyone! Mike helped calm all my fears and anxieties as I was trying to navigate one of the hardest and most stressful times in my life. Thank you from the bottom of my heart Mike and Shirley!!

- Jen Thompson
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"Cardamone Law Firm were very helpful to me since day one. Michael and Shirley are very dedicated to my case giving me updates, answering my questions, being honest with my case, and getting the maximum amount favorable to my case. Thank you so much for your service and dedication and helping me to achieve not only your case but to guide and refer me in other needs too! You guys are the best law firm friendly and dedicated. I will recommend to anyone."

- A. Ortiz
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"Michael won my workers comp case after my employer insurance denied my claim."

"Exceptional firm. Highly recommend this law firm. Michael won my Workers Comp case after my employer insurance denied my claim. Him and his staff were always at my reach for legal and emotional support. Am so happy I hire them. Thanks Michael and Ms. Shirley."

- Carlos P.
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"[They] did an excellent job in getting me financially compensated in a fairly short amount of time."

"I recently had a work related injury and was receiving Workers' Compensation (medical benefits only). Soon after I was fired, so I contacted Paul Silver at Cardamone Law Firm who did an excellent job in getting me financially compensated in a fairly short amount of time. Paul and his assistant Shirley always responded to any questions I had about the case in a very short amount of time. Thank you for helping me with this difficult case."

- Robin C.
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"Cardamone Law was great with helping my husband with his Workers Comp issues. Mike and Shirley were the best with letting us know what was going on every step of the way. Highly recommend."

- Danielle P.
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"Mike Cardamone is amazing"

"Mike Cardamone is amazing. He is "hands down" one of the best lawyers I've ever had the privilege of knowing. He is very kind, understanding, knowledgeable in his field, always very thorough and helpful. He was extremely professional and someone who truly cares about his clients. I felt completely at ease with him. He was a pleasure to work with, explained everything in detail, as well as answered all my questions with knowledge and care. If you want someone you can trust, who communicates every step of the way, will fight for you and make sure you win your case, he is it! I will refer all my family and friends to him. Thank you so much Mike, for everything. I appreciate all your hard work and dedication in helping me."

- Allie M.
Google Reviews
"Best Workers' Comp Lawyer!"

"Michael is simply the best! He was there for me from day 1 till the end, and we won the case!! He is always available to help. I had a gazillion questions and he would answer them one by one. He's a great lawyer and I feel lucky to have found him online from reading other outstanding reviews about him. Believe me, they're true!"

- Faith B.
Google Reviews
"Great Attorney"

"Great attorney, handled case quickly and efficiently. I would recommend him and would use him again. He was always available to answer any questions we had. Thank you, Mr. Cardamone."

- H. Anderson
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