What Is the Workers Comp Utilization Review Process?
Many injured workers receive benefits to cover lost wages and medical expenses from a workplace injury. However, there are a number of things that have to happen before those checks start to arrive.
One of those is the utilization review process. This involves a nurse or doctor reviewing whether the medical treatment is reasonable and necessary.
The Initial Review
The workers’ compensation utilization review process determines whether or not an injured worker’s medical treatment is reasonable and necessary. Insurance companies want to be sure they’re not paying for unnecessary services. They also have to comply with state regulations and policies. Those rules impose strict timelines for review decisions and require specific protocols for handling a request.
Typically, when an injured worker’s physician recommends treatment, they submit the RFA form to the insurer for approval. It’s a standard medical document that includes the diagnosis, dates of service, and documentation of the treatment plan. The RFA must be signed with a handwritten original signature to be legally binding. It is then sent to the UR department for evaluation and review of the medical necessity of the requested treatment.
When the RFA is received, the UR nurse or team reviews the medical record and compares it to the evidence-based guidelines. These guidelines include ODG, which outlines the recommended course of care for injured workers. For example, the ODG guidelines recommend physical therapy for low back pain. Consequently, the UR nurse may conclude that the MRI is not needed at this time.
If the UR nurse makes an adverse decision, the injured worker or their attorney can request a reconsideration. This is usually done in writing, but it may be initiated verbally. The UR agent is required to provide the injured worker or their representative with the opportunity to communicate orally with a practitioner of the same school on an expedited basis. The UR agent should also request that the injured worker or their provider follow-up with a written appeal request.
During the reconsideration phase, an independent review physician is assigned to evaluate the case and make a final determination. It is important to have a physician who understands the current standards of care and knows how to apply them to the specific case at hand. That’s why Concentra’s URAC-accredited medical review team, Medical ReviewStream, provides peer reviews that meet the highest quality standards.
If the independent reviewer upholds a denial by UR, the injured worker or their representative can choose to file an IMR. This process is outlined in California’s DWC regulations, and the IMR must be filed within 20 days of receiving the UR denial letter.
The Reconsideration
Getting workers’ comp benefits to pay for your injury can reduce some of the financial stress you face while undergoing treatment for a work-related accident or illness. However, there are a lot of things that need to happen before those checks start showing up in your mailbox. One important process is called a utilization review. This is the process an employer or its workers’ compensation claims administrator uses to determine whether a proposed medical treatment for a workplace injury is medically necessary. The California Division of Workers’ Compensation has regulations, governed by Labor Code section 4610 and Title 8, California Code of Regulations sections 9792.6 et seq, that lay out the timeframes and other rules for conducting a UR.
A UR begins with the submission of your proposed treatment plan to your treating physician. Your doctor then reviews it for compliance with medical treatment guidelines and makes a recommendation to the insurer as to whether or not the plan is medically necessary. The insurer then either authorizes the plan or denies it. If the UR decision is denied, your treating doctor then has 10 days to perform an UR appeal with the UR company. Your lawyer can help you fill out the correct forms to submit to the UR company.
If your UR appeal is rejected, you can then file an independent medical review (IMR). In Dubon II, the WCAB stated that IMR jurisdiction only exists when the UR decision was untimely and the disputed issue involved significant prejudice or irreparable harm.
After IMR, your case may then go to a WCAB judge for a final decision. This is the last level of appeal for a UR denial, but it can be expensive and time-consuming. It can also be difficult to persuade a WCAB judge to change the previous decision.
With medical expenses making up more than 60 percent of all workers’ compensation costs, it’s vital that you have an experienced attorney standing by your side to ensure that you get the care and the payments you deserve. This is particularly true when it comes to a utilization review or any other step in the workers’ comp process.
The Appeal
The workers’ compensation system exists to ensure that injured workers have a safety net of benefits to cover missed wages and medical expenses while they recover from their injuries. But there are a lot of processes that have to happen before those checks start showing up in the injured worker’s mailbox, and one of the most important is called utilization review.
Generally, when an injured worker’s treating doctor proposes treatment, the insurance company will send it to a workers’ comp utilization review department, where an independent group of medical professionals will decide whether the proposed treatment is in fact medically necessary. If it isn’t, the insurance company will not pay for the treatment.
There are a few different types of UR, including precertification, concurrent and retrospective reviews. During precertification, the physician’s request for treatment is evaluated by a nurse who uses guidelines to decide if the procedure is appropriate. If the nurse can’t approve the request, it will be sent to a physician reviewer who makes a decision using evidence-based guidelines and clinical judgment. The physician and injured worker are notified of the reviewer’s decision.
If the reviewer decides that all or part of the treatment is not reasonable and necessary, he or she must provide written rationale explaining why. Then, the injured worker can submit additional documentation to appeal the UR decision.
If you’re in the midst of a workers’ comp utilization review, it’s important to have an experienced attorney on your side to protect your rights. An attorney can help you understand your options, navigate the process and fight for the medical care you deserve. Moreover, an attorney can help you understand the complex legal and medical terms used in workers’ comp UR decisions, as well as the procedures for appealing them. Contact a knowledgeable workers’ comp attorney today to schedule a free consultation.
The Final Decision
With medical expenses accounting for more than 60 percent of average workers’ compensation costs, it is essential that only the most necessary treatment is provided to injured employees. Fortunately, the law provides an effective method of limiting such expenditures through utilization review.
Basically, it involves the insurance company examining whether or not a specific medical treatment is medically reasonable and necessary. If the insurer is unable to make such a determination, it must send the case to a physician for review. After the review, a decision will be made. The injured worker and his or her doctor will receive a letter informing them of the outcome of the review. The letter will also contain the name, address and license number of the reviewer and provide a detailed explanation of why the recommended medical treatment is or is not medically necessary.
The reviewer may decide that all or part of the recommended treatment is medically reasonable and necessary, in which case the treatment will be authorized and the insurer must pay for it. The reviewer may also decide that the recommended treatment is not medically reasonable and necessary, in which case it will be denied and the injured worker must appeal that decision by filing a petition for review with the workers’ comp judge.
If you disagree with any decisions affecting your workers’ compensation claim, it is important to contact a workers’ compensation lawyer as soon as possible. A knowledgeable attorney can help you fill out the appropriate forms to file a medical legal dispute evaluation and/or workers’ comp appeal.
