What is a utilization review?
Your employer or their workers’ comp insurance carrier will decide whether your treatment is medically necessary. Here’s what you need to know.
Workers’ Compensation will pay for your medical care after an on-the-job injury, but workers’ comp only pays for treatment that is reasonable and medically necessary. Your employer, or more likely their claims administrator, has a program in place called Utilization Review (UR) which they use to determine whether treatment is medically necessary.
The California Code of Regulations provides medical treatment guidelines and rules regarding the determination of what constitutes reasonable and necessary medical care. These guidelines are called the Medical Treatment Utilization Schedule (MTUS). The MTUS outlines what kinds of treatments have been scientifically proven to treat or cure different kinds of work-related illnesses or injuries. When conducting a Utilization Review, the claims administrator will refer to the MTUS to decide whether your doctor’s recommended treatment falls within the guidelines of reasonable and necessary medical care.
To avoid a problem with the claims administrator, your physician should only be recommending treatment that is either in the MTUS or is based on other scientifically-based guidelines that are generally accepted in the medical community.
UR process and timelines
It’s important that you get treated promptly for your injury, and the California workers’ compensation system puts in specific timelines to ensure any questions about your treatment get resolved in a timely fashion. Once your doctor requests a particular form of treatment, the claims administrator has five days to conduct and complete a UR, including making a decision on the requested treatment. In some cases, the administrator can ask for additional information and have up to 14 days to render a decision.
An expedited review process is also available for critical or emergency treatment. If you are in the hospital and your doctor says you are facing a serious threat to your health that can’t wait for the regular UR process, then the expedited review process can kick in. Under an expedited review, the claims administrator has to make a decision within 72 hours after receiving the information they need about the treatment. For more serious conditions that can’t even wait 72 hours, the administrator must make its decision sooner.
After the UR has been concluded, the administrator could approve the recommended treatment, alter it or deny it. Treatment can only be modified or denied by a doctor familiar with the specific type of injury or illness at hand.
If the recommendation is to change or deny the treatment recommended by your doctor and you disagree with this result, you can request an Independent Medical Review (IMR). You should receive a completed IMR request form along with the determination letter that modified or denied your treatment request. All you have to do to kickstart the IMR process is sign that form and mail it in the pre-addressed envelope provided with the form.
A workers’ compensation attorney can help you with a UR
Remember that when you get treated for an on-the-job injury, your doctor bills the insurance company directly so you don’t pay out of pocket. Any dispute over the doctor’s treatment, therefore, is really a dispute between the doctor and the insurance company regarding how the physician will get paid. This process shouldn’t impact you financially or affect your treatment, but you can wind up stuck in the middle, be forced to attend IMRs, and you might worry whether your doctor is recommending the best treatment for you or is being pressured by the insurance company to provide some other treatment.
The UR process works best if your doctor is proactive in staying in contact with the claims administrator’s doctor throughout the process. However, your doctor might be too busy and might need your help dealing with workers’ comp, such as filing a declaration of readiness for an expedited hearing. Your workers’ compensation attorney can answer all your questions about the UR process and help ensure that it proceeds smoothly and concludes in a timely manner. If you are having trouble getting the treatment you need or if your requested treatment has been denied, contact a workers’ compensation lawyer for help.
