The Workers’ Compensation Act allows the workers’ compensation insurance company to seek review of the reasonableness and necessity of medical treatment for a work injury. It is called a Utilization Review. It is important to note that the review is limited to the reasonableness and necessity of the treatment. It is NOT a review of whether the treatment is related to the work injury.
The review is initiated when the insurance company files a Utilization Review Request with the Bureau of Workers’ Compensation. You should know that when the Request is filed the insurance company can stop paying medical bills in dispute until the review process is concluded and results in a favorable determination for the injured worker.
The review is assigned to an authorized Utilization Review Organization and the review organization will request the medical records and forward the review to a doctor or provider of similar specialty as the doctor under review. It is critical that the provider under review forward the medical records as requested. Failure to do so will lead to a final determination that the treatment is unreasonable and unnecessary.
There are a number of important timelines built into the process. From the perspective of the injured worker, you will have an opportunity to submit a written statement for the reviewer’s consideration. That statement must be submitted within 10 days of the assignment of the review. It is a good idea to submit a statement to tell the reviewer about the treatment and how it is helpful.
Eventually, the reviewer will issue Utilization Review Determination. That report will detail the treatment and give, in effect, a determination. If the treatment is found reasonable and necessary, the insurance company must pay the bills for the medical treatment. If it is found to be unreasonable and unnecessary, it does not. Both the injured worker and the insurance company can appeal an unfavorable determination to a Judge. This is an important right. Further, there are tight timelines for the appeal, so consult your Lancaster PA workers comp lawyer immediately.
The Utilization Review process is a very powerful tool for the insurance company. The results of the Review can have dramatic consequences for the injured worker. Don’t go it alone! If you receive a Request for Utilization Review consult a Workers Comp Specialist right away! Know your rights. Call now for a free consultation with a Certified Workers Comp Specialist – (717) 584-9429.