Workers’ compensation insurance companies are always looking for ways to limit the amount of money they are required to pay on claims. One of their weapons is a utilization review (U.R., for short) which they often file to challenge whether treatment an injured worker is receiving for his work injury is reasonable and necessary. Let’s take a look at the process and what you can expect if a U.R. is filed in your case.
Let’s suppose that you injured your back at work two years ago and the insurance company accepted your claim. They are paying you wage loss benefits as well as your medical bills for treatment which you have been receiving. The last several months, you have been treating primarily with a pain management doctor who prescribes you with medication and injections to your back. This treatment provides you with pain relief and improves your ability to function.
The insurance company for your employer then files a U.R. against your pain management doctor. The Bureau of Workers’ Compensation will appoint a pain management physician to review the records of your doctor and the records of other doctors with whom you have treated. (The reviewing doctor must be of the same specialty as the doctor whose treatment is being challenged; if you were undergoing chiropractic treatment, a chiropractor would be appointed.) Your doctor will be given the opportunity to speak with the doctor conducting the review and vouch for the treatment that he has been providing you as reasonable and necessary. You are permitted to submit a short written statement, explaining why you believe the treatment is beneficial.
The doctor appointed by the Bureau will then write a report, summarizing the records and offering an opinion on whether the treatment provided by your pain management physician is reasonable and necessary. The doctor will arrive at one of three opinions:
- All treatment is reasonable and necessary
- None of the treatment is reasonable and necessary
- Part of the treatment is reasonable and necessary and part is not. The reviewing doctor may find that your pain management doctor’s treatment up to a certain date was reasonable and necessary, but then was unreasonable and unnecessary after that date. The reviewing doctor may also find that some of the treatment (for example, the medication your doctor is prescribing) is reasonable and necessary, while other facets of his treatment (for example, the injections) are unreasonable and unnecessary.
Both you and your employer’s insurance company have the option to file an appeal within 30 days in response to the determination made by the reviewing doctor. So if you are dissatisfied that the reviewing doctor found that some or all of your treatment is unreasonable and unnecessary, you may file an appeal and your case will be heard by a workers’ compensation judge. You will have the chance to testify and convince the judge that the treatment is reasonable and necessary. You can describe the benefits which you have obtained from the treatment and that you will have increased pain and decreased ability to function on a daily basis if you can no longer receive the treatment. During this process, the insurance company may require you to undergo an independent medical evaluation with a doctor of its choice who will examine you, review the records, and provide an opinion on whether the treatment is question is reasonable and necessary. Your pain management physician will be able to write a report defending the treatment. The judge will then issue a decision, deciding whether the treatment in question is reasonable and necessary.
You don’t want to go through this process without an experienced workers’ compensation lawyer by your side. So if a utilization review has been filed against one of your doctors, please call Pearson Koutcher Law and speak with one of our experienced lawyers. In fact, even if a utilization review has not been filed but you have injured yourself at work and have questions, contact Pearson Koutcher Law. We will be happy to represent you and file any necessary petitions on your behalf.
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