What is a workers’ compensation utilization review?

When Pennsylvania workers suffer a job-related injury, they might be under the impression that workers’ compensation benefits will be there to protect them, provide medical coverage and for wage loss. In many cases, that is exactly what the system does. However, the circumstances can differ depending on the case. Since challenges frequently arise, it is imperative to have experienced advice throughout a case. One potential factor that could be a concern is a utilization review.

Review of medical treatment

The utilization review (UR) centers on the medical treatment being provided. A review can be requested by the insurance company, the employer or the worker. If, for example, the insurer does not think a specific type of treatment is required based on the worker’s injuries and prognosis, then it can ask that a UR be conducted. The case will be assessed by a utilization review organization (URO). It will look at the medical information, the treatment and when that treatment was requested. A reviewer will receive this packet and determine whether the treatment is “reasonable and necessary.” The decision comes slightly more than two months after the filing has been made.

Workers can provide their perspective to the URO about the treatment. Once the determination is made, the worker can ask for a copy of it. Perhaps it says that the worker does not need a certain treatment, but the worker still feels as if it is needed. This can be problematic because if the URO decides that treatment is not needed, then the insurer nor the employer will be asked to pay for it. Obviously, this can lead to a disagreement and fear as to what the future will hold.

If a UR results in denied medical treatment, the worker still has options

This might be confusing for younger, blue-collar workers who do not consider underlying factors in a workers’ compensation case like disputes over the extent of the injury, how long the worker will be off the job and what happens if there is a gap between what the worker says and what the treating physicians say. For people like factory workers and construction workers who need to be at full capacity to do their jobs, this is important. It is also crucial for anyone who has suffered an employment-related injury. Being denied treatment can be worrisome, but there are alternatives. Having advice from the outset can help.