Utilization Review Explained

By: Douglas A. Williams

If you have been injured in a work injury, and are actively treating with a doctor, you may receive a “Utilization Review Request” in the mail. This document is often particularly confusing to those who aren’t in the legal profession. Many injured workers wonder whether the Utilization Review Request is an attempt to stop their weekly checks. Others fear the request may mean that they will be stuck paying medical bills.

When an insurance carrier files a Utilization Review Request, the carrier asks the Bureau of Workers’ Compensation to appoint an independent doctor to review the “reasonableness and necessity” of the injured worker’s treatment. So, for example, if the injured worker is seeing a chiropractor two times per week, the independent doctor would decide whether the worker needs to treat that frequently and whether the type of treatments provided by the chiropractor are reasonable and necessary. If the independent doctor finds the treatment reasonable and necessary, the insurance carrier must continue to pay for it. If the doctor determines that the treatment is unreasonable and unnecessary, the carrier is no longer responsible for paying for treatment with that doctor.

Injured workers should know that, regardless of how the Utilization Review Request is decided, his weekly checks will not be affected. Additionally, if the insurance carrier is excused from paying for treatment, the doctor is forbidden by law from billing the injured worker. Furthermore, the Utilization Review Request relates to the treatment provided only by the doctor who is the subject of the review. Finally, the doctor, the injured worker, or the insurance carrier has the right to appeal the Utilization Review doctor’s decision to a Workers’ Compensation Judge.



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