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Injured workers: be aware of the utilization review process

Utilization review is a process by which employers or claims administrators are able to look at an injured worker’s course of treatment to determine whether everything was or is medically necessary. The process is intended to ensure that spending in the California workers’ compensation system is efficient and evidence-based. Medical necessity pertains not only to specific treatments recommended for specific injuries, but also to the frequency, extent and length of the proposed treatment.

Ideally, utilization reviews are conducted prior to delivery of the medical treatment so as to give the patient and physician notice. By law, a claims administrator must perform a review and render a decision within five days of the doctor’s request of the treatment, though additional time may be granted in some situations. It is possible for a doctor to request an expedited review when there is a serious health threat which must be addressed immediately.

For treatment which is already delivered, reviews must be done and given to the doctor within 30 days. Usually, though, a claims administrator’s refusal to pay for a treatment which has already been provided is something doctors and claims administers have to settle among themselves without involving the injured worker.

The rules governing utilization review are laid out in the California Labor Code, which calls for penalties when the rules are not followed. Injured employees who believe the party that reviewed their doctor’s treatment recommendations was incorrect on the question of medical necessity do have the ability to file a complaint with the Division of Workers Compensation. In cases where one agrees with the treatment requested by one’s doctor and that treatment is denied in a utilization review, an injured worker is not without recourse. In our next post, we’ll discuss the process by which these decisions can be challenged.

Source: Department of Industrial Relations, “Utilization review,” Accessed Dec.22, 2014.  

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