Your Medical Treatment is Under Utilization Review, What Does That Mean?
A Utilization Review (UR) is a process used by employers or insurance companies to determine whether medical treatment for a work injury is reasonable and necessary under Pennsylvania workers’ compensation law. If treatment is challenged, an independent reviewer evaluates the care being provided. Injured workers have the right to appeal an unfavorable Utilization Review decision and may be able to continue receiving coverage for treatment that provides a medical benefit.
What Is a Utilization Review in Pennsylvania Workers’ Compensation?
Under the Pennsylvania Workers’ Compensation Act, employers and insurance companies can challenge medical treatment they are paying for by requesting a Utilization Review (UR).
A Utilization Review does not determine whether your injury is work-related. Instead, it focuses on whether the medical treatment you are receiving for an accepted work injury remains reasonable and necessary.
The goal of a UR is often cost containment. If the insurance company can prove certain treatment is no longer necessary, it may no longer be responsible for paying those medical bills.
Many injured workers become concerned when they receive notice that a Utilization Review has been filed. However, a UR does not automatically mean your treatment will stop, nor does it mean you have lost your workers’ compensation case.
Why Do Employers File Utilization Reviews?
Employers and workers’ compensation insurance companies commonly file Utilization Reviews when they believe:
- Physical therapy is continuing for too long
- Chiropractic treatment is no longer necessary
- Pain management treatment should be reduced
- Certain prescription medications are unnecessary
- Specialist visits are excessive
- Medical treatment is unrelated to the work injury
In many cases, the insurance company is simply trying to reduce its financial responsibility for ongoing medical care.
What Happens During the Utilization Review Process?
Once the employer or insurance company receives medical bills related to your work injury, it may file a Utilization Review Request.
A Utilization Review Organization (URO) is then assigned to review the treatment in question. The review is performed by a healthcare provider with the same or a similar specialty as the provider whose treatment is being challenged.
For example:
- A physical therapist reviews physical therapy treatment
- A chiropractor reviews chiropractic treatment
- A pain management specialist reviews pain management care
The reviewer examines your medical records and issues a Utilization Review Determination (URD), which states whether the treatment is reasonable and necessary.
The determination may find that:
- All treatment is reasonable and necessary
- Some treatment is reasonable and necessary
- Certain medications or procedures are not reasonable and necessary
- Ongoing treatment should no longer be covered
What Happens if the Utilization Review Is Unfavorable?
If the Utilization Review Determination concludes that some or all of your treatment is not reasonable and necessary, you still have options.
Pennsylvania law allows injured workers to challenge an unfavorable Utilization Review Determination by filing a Petition to Review Utilization Review Determination.
This petition asks a Workers’ Compensation Judge to review the evidence and decide whether the treatment should continue to be covered.
An unfavorable UR decision does not automatically mean you lose your right to treatment.
How Do You Prove Medical Treatment Is Reasonable and Necessary?
One of the biggest misconceptions about Pennsylvania workers’ compensation treatment is that medical care must cure your injury to remain covered.
That is not true.
Treatment can still be considered reasonable and necessary even if it:
- Only provides temporary pain relief
- Helps manage symptoms
- Improves daily functioning
- Maintains your current condition
- Prevents worsening symptoms
This is known as palliative treatment, and Pennsylvania workers’ compensation law often recognizes its value.
To challenge a UR, your attorney may present:
- Testimony from your treating doctor
- Medical reports explaining the treatment plan
- Medical records documenting improvement
- Your own testimony regarding how the treatment helps you
Your testimony is often critical because it allows the Judge to understand the real-world benefits you receive from treatment.
Don’t Stop Treatment Without Speaking to an Attorney
Many injured workers panic when they receive an unfavorable Utilization Review Determination and immediately stop treatment.
In many cases, that is a mistake.
If the treatment helps manage your symptoms or improve your quality of life, you should speak with an experienced Pennsylvania workers’ compensation attorney before making any decisions about your care.
The right legal strategy may allow you to continue receiving treatment and force the insurance company to remain responsible for the costs.
Talk to a Pennsylvania Workers’ Compensation Lawyer
A Utilization Review can be intimidating, but it does not mean your medical treatment has to end. Pennsylvania workers’ compensation law gives injured workers the right to challenge unfavorable Utilization Review Determinations and fight for the treatment they need.
At Stern & Cohen, we regularly represent injured workers in Utilization Review disputes involving physical therapy, chiropractic care, pain management treatment, prescription medications, and other medical care related to work injuries. If your treatment has been challenged by the insurance company, our team can help protect your rights and pursue continued coverage.
Contact Stern & Cohen today for a free consultation.
FAQs
What is a Utilization Review in Pennsylvania workers' compensation?
A Utilization Review (UR) is a process used to determine whether medical treatment for a work injury is reasonable and necessary. Employers and insurance companies often request a UR when they want to challenge ongoing treatment, medications, physical therapy, chiropractic care, or specialist visits.
Why would the insurance company file a Utilization Review?
Insurance companies typically file Utilization Reviews to determine whether they should continue paying for certain medical treatment. In many cases, the insurer believes the treatment is excessive, no longer necessary, or unrelated to the accepted work injury.
Does a Utilization Review mean my workers' compensation claim was denied?
No. A Utilization Review only addresses whether specific medical treatment is reasonable and necessary. It does not determine whether your work injury is covered by workers’ compensation.
Can my medical treatment continue while a Utilization Review is pending?
Often, yes. Many healthcare providers will continue treatment while the Utilization Review is being completed. However, payment for the treatment may remain in dispute until a determination is issued.