Your Medical Treatment is Under Utilization Review, What Does That Mean?

February 21, 2021
Stern & Cohen
utilization review workers comp

Many people who receive medical treatment under the Workers’ Compensation Act, regardless of whether their employer initially accepted their claim or if your case has gone through a round of litigation, may at some point receive a notice of Utilization Review (“UR”). 

Utilization Review Explained

The Workers’ Compensation Act provides for a utilization review process by which all treatment provided by a health-care provider under the Act may be subject to prospective, concurrent, or retrospective utilization review at the request of an employee, and employer, or an insurer. The most common reason an Employer files a Utilization Review Request is for cost containment. In other words, your employer is trying to establish whether your medical treatment is still medically necessary because if it is not, they no longer have to pay the bills. 

Once an employer has received medical bills referable to your work injury, they are entitled to file a UR request within 30 days of receipt of the medical bill. When a UR request is filed, payment for the treatment in question is under dispute. During the time it is in dispute, those bills will not be paid under the Act until the dispute is resolved.  DO NOT WORRY – most providers are still willing to provide you treatment even with this pending.  If not, the lawyers at Stern & Cohen will have a solution for you.  We will not let this get in the way of you obtaining the necessary care for your work injury!

The UR request can cover a range of treatments. For example, if you are treating with a pain management doctor for your work-injury and the treatment is covered under the Act, your employer could be disputing the reasonableness and necessity of you seeing that specialist at all, or they could simply be stating that a certain type of treatment, such as a certain medication, or the frequency at which you see the specialist is not reasonable.  An organization called the Utilization Review Organization performs the review. What this means is that a provider licensed in the same profession and having the same or similar specialty as the treatment rendered by the health care provider under review determines the reasonableness and necessity of the treatment in question. For example, if your employer files a UR request regarding physical therapy you receive, a physical therapist from the Utilization Review Organization will review your medical records and determine if your treatment is still needed. After reviewing the medical records related to the work injury, including the treatment under review, the Utilization Review Organization will issue a report, called a Utilization Review Determination (“URD”). 

A URD is a report indicating whether the treatment under review, relating to a specific period of time, is medically reasonable and necessary. If the reviewer decides that all or part of the treatment under review is not reasonable and necessary, they must explain the basis. If the reviewer determines the treatment is not reasonable and necessary, the injured worker has a right to challenge the URD, which is called a Petition to Review Utilization Review Determination. 

By filing this Petition, the worker is indicating that they need this treatment and it helps in some way. It is important to note that even when the worker files a Petition to Review Utilization Review Determination, the Employer still has the burden of showing the treatment is not needed, because they are the ones trying to stop their obligation to pay workers’ compensation work-related medical expenses.  Our firm is very adept at litigating these issues.

How Do We Prove The Treatment is Reasonable and Necessary?

First, we will have the provider under review either testify as to the treatment in question or issue a report indicating the reasoning behind the treatment and its relation to the work injury. Further, and most importantly, the worker will be allowed to testify specifically about the treatment they receive. 

We have used the term “reasonable and necessary” several times at this point. It is very important to note what “reasonable and necessary” means under workers’ compensation laws. The following are situations that qualify as reasonable and necessary treatment: treatment that is merely palliative in nature and provides no lasting benefit, treatment designed to manage the employee’s symptoms rather than cure or permanently improve the condition, treatment for pain that does not increase the employee’s physical capacity. 

Practically speaking, if you receive any benefit from treatment that is related to your accepted work injury, you are entitled to continue that treatment. The treatment does not need to “heal” or “cure” you to be deemed reasonable and necessary.  Our lawyers have vast experience at developing and presenting this testimony from our clients.

Let’s take a look at how this might look in a real case. In this hypothetical, you are involved in a work-related accident in January 2020 and injure your back. Your employer accepts your injury and you begin treating with doctors, including a chiropractor and a pain management doctor, using the workers’ compensation insurance. Now, after a few months of treatment, your employer files a UR request relating to treatment with your pain management doctor and chiropractor from April 2020 and ongoing. This indicates your employer is not sure that they should still be treating for those specific doctors as of April. The Utilization Request Organization will have two reviewers, one chiropractor and one pain management doctor, review your medical records and determine whether you still need to be treating for your injuries with these providers starting April 1, 2020, through the present. 

In this hypothetical, a UR Determination comes back in June 2020 and indicates that the treatment with your pain management doctor is reasonable and necessary, except for one prescription during the period under review, and that no chiropractic treatment is necessary as of April 1, 2020, and ongoing. In the meantime, you had continued treating with both providers for the two months while treatment was under review, and now there are outstanding medical bills.

What Should You Do?

You should have your attorney file a Petition to Review Utilization Review Determination. It is important to note that if you do not have an attorney already, you should get one. As mentioned above, we will submit medical evidence from the providers in question that support the medical necessity of the treatment. Further, you will have the opportunity to submit an affidavit and testify, either via deposition or at a hearing in front of a Judge, regarding your treatment. 

This testimony is your opportunity to explain why you need the medical treatment and what benefit you get from it. As noted above, the treatment does not have to cure you. Rather, as long as you receive some benefit, even if temporary, you are entitled to continue treatment. For example, if the prescription medication that was determined to be unreasonable and unnecessary helps you manage your pain levels, then it is reasonable and necessary. Even if you are still unable to work while on it, if there is some palliative benefit, then it should continue to be covered under the Act. Similarly, if you receive benefit from chiropractic treatment, even if only for a few hours after treatment, then the treatment should continue to be paid for. 

The most important thing to remember if you receive an unfavorable Utilization Review Determination is to not panic. If you believe you benefit from the treatment under review, keep treating with that provider and have your attorney file a Petition to Review the Utilization Review Determination. The most important thing to focus on is your recovery. 

Contact Us – the consultation is always free.