Close

How Does Utilization Review Work In A Pennsylvania Workers’ Compensation Case?

UTILIZATION REVIEW: A METHOD THAT WORKERS’ COMPENSATION INSURANCE COMPANIES USE TO AVOID PAYING BENEFITS

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.

Pennsylvania Workers Compensation Case
Image Source: pexels.com/Karolina Grabowska

What Is 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 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 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 Pennsylvania workers’ compensation attorney will know how to properly present the case to achieve the best result for the client.

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

Awards & Recognitions

Pennsylvania Workmans Comp Attorney
Philadelphia Workmans Comp Lawyer

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

$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury
& Hundreds More Cases
$2.2 Million
Spinal Injury
$897,000
Lower Back Injury
$650,000
Lower Back Injury
$550,000
Neck Injury
$425,000
Leg Injury
$375,000
Knee Injury
$325,000
Ankle Injury
& Hundreds More Cases

Client Testimonials

"Best Law Firm around!"

"Cardomone law is absolutely fantastic! They are very responsive and helpful and they will fight to get you what you deserve. Shirley is also very helpful whenever you have any questions! Best Law Firm around!"

- C. Edwards
Google Reviews
"Michael and Shirley are very dedicated...and getting the maximum amount favorable to my case"

"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
Google Reviews
"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.
Google Reviews
"[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.
Google Reviews
"Highly recommend."

"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.
Google Reviews
"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
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."

- L. Edall
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
Google Reviews