Utilization Review in a Pennsylvania Workers’ Compensation Case

Under Pennsylvania’s workers’ compensation law, a utilization review is a tool usually used by the workers’ compensation carrier to review the reasonableness and necessity of medical care and treatment rendered to the injured worker.  It is a way for the carrier to deny payment in order to save money on a case.

A utilization review can take three forms, which are prospective, concurrent, or retrospective.

Prospective review is performed prior to the treatment of the questioned medical procedure.  This could be in the form of the adjustor needing to pre-certify the payment of the wanted treatment.  An example would be if the injured workers’ doctor prescribes an MRI, the workers’ compensation carrier would have to agree to pay it, before it is actually done.  Concurrent review is conducted simultaneously with the medical procedure or treatment.  The retrospective review is carried out following the treatment or medical procedure in question.

Typically, the most common type of review is the retrospective, which is triggered by the carriers’ receipt of the bill from the medical facility where the treatment was performed.  Once a bill is received, the carrier has 30 days to either pay or deny the bill, or the alternative of requesting that a utilization review be performed.

Once the workers’ compensation carrier has determined that they are questioning the reasonableness and necessity of medical treatment, they can request from the Pennsylvania Bureau of Workers’ Compensation that an independent third party known as a utilization review organization perform the review of the treatment method, duration, and the reasonableness and necessity of the same.  The Utilization Review organization will be sent all of the treatment notes from the provider under review, be given the opportunity to speak with the provider regarding the treatment, and then will be responsible for writing a report as to the details of the treatment and whether or not all or part of it was reasonable and necessary.

The unbiased utilization review organization typically has the same type of physician perform the review as the provider under review.  This could be an orthopedic surgeon reviewing another orthopedic surgeon.

The outcome of the utilization review can take three forms.  If all of the treatment is found to be reasonable and necessary, and then the workers’ compensation carrier would be responsible for payment of the bills.  If the treatment is found to be not reasonable or necessary, then the carrier can refuse to pay for the treatment; however, if the injured worker then files an appeal to that determination, then it will go before a workers’ compensation judge to hear evidence and make a final determination. A third option is that some of the treatment is and some is not reasonable and necessary, and again, the injured worker could take an appeal, of course looking for an eventual ruling that all of the treatment is reasonable and necessary, and therefore should be paid for.female attorney engaged in conversation with a man and woman

As these utilization reviews can be complicated and deal directly with your treatment for your workers’ compensation injury, it is a very wise idea to consult with a qualified workers’ compensation attorney to navigate your way through the same.