For Injured Workers seeking medical treatment for their workers’ compensation claims, Utilization Review (UR) of their Physician’s Requests for Authorization for medical treatment is all too common. Injured Workers often receive letters denying treatment, modifying treatment, deferring treatment authorization, requesting further information and certifying treatment. These letters are generated by the Insurance Companies via their Utilization Review process.
This article will briefly discuss the history of Utilization Review, what is Utilization Review, why the workers’ compensation system employs UR, and how an Injured Workers should address UR.
What Is the History of Utilization Review?
“Background Utilization management has been defined by the Institute of Medicine as “a set of techniques used by or on behalf of purchasers of health benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision.”[1] Utilization management is used in an effort to discourage the use of unnecessary or inappropriate medical services, without jeopardizing necessary high-quality care.
The terms “utilization management” and “utilization review” (UR) are used interchangeably in this report. By the late 1980’s, UR had become ubiquitous in health care, effecting virtually everyone with any form of health insurance coverage in the U.S., and many workers’ compensation claims administrators had also begun to use UR as a cost-containment tool.” Utilization Review in California’s Workers’ Compensation System: A Preliminary Assessment July, 2001 Division of Workers’ Compensation Public Health Institute Department of Industrial Relations Berkeley, California State of California [emphasis added]
What is Utilization Review?
“Utilization management is a set of techniques used to manage health care costs through the assessment of the appropriateness of care in individual cases. The primary focus of utilization management is reduction of the use of unnecessary or inappropriate medical services.” Utilization Review in California’s Workers’ Compensation System: A Preliminary Assessment July, 2001 Division of Workers’ Compensation Public Health Institute Department of Industrial Relations Berkeley, California State of California
In layman’s term, managing health care costs saves Insurance Companies money by denying treatment. Denying treatment leads to less bills. Less bills leads to less costs.
What are the Reasons for Utilization Review?
Medical costs within the workers’ compensation system are driven my multiple factors. These can include fraud, overuse, and greed.
First, fraud in workers’ compensation could include prescriptions for expensive and unnecessary treatment.
Second, overuse in workers’ compensation involved Injured Workers who were enthusiastic about their treatment and had providers who would enable it. For example, before UR, there were individuals with minor back injuries with open medical awards that would seek chiropractic adjustments 3 days a week in perpetuity.
Third, greed and distrust of medical providers. There is a distrust by insurance Companies of medical providers. Medical providers may be incentivized to provide treatment to make money versus providing the care that was needed. For example, epidural injections, at one point in time, became increasingly used. Arguably, they were done because they were profitable for the providers rather than helpful to the Injured Workers.
How Should Injured Workers Address Utilization Review?
Injured Workers need to address utilization review by choosing treating doctors who are responsive to the UR process. Further, Injured Workers should be aware of UR denials and the need to file for Independent Medical Review.
An Injured Worker should choose the right treating doctor for UR processes. An Injured Worker should look for treating doctors who understand the utilization review process. This means that the doctors should understand the forms that need to be filled out to get treatment approval. This means that the doctors should understand the treatment utilization schedules as to what treatment can be approved and how to request it. Finally, the doctor should be responsive to inquiries from utilization review when they request peer to peer discussions as well as requests for supplemental reports.
Also, Injured Workers need to have treating doctors who will be responsive to the utilization review company’s requests for further information.
What if I Need Advice?
If you would like a free consultation regarding workers’ compensation, please contact the Law Offices of Edward J. Singer, a Professional Law Corporation. We have been helping people in Central and Southern California deal with their workers’ compensation cases for 27 years. Contact us today for more information.