The Utilization Review Process in a Workers Compensation Case
The workers compensation insurance company has the right to challenge the medical treatment a claimant is receiving from a workers compensation injury. The process is called a utilization review. The Pennsylvania Workers Compensation Act allows the insurance company to file a the review asking that some or all of the treatment that a specific medical provider is giving the injured worker to determine if that treatment is reasonable, necessary and related to the accepted work injury. Once the review is filed, an “independent” medical provider (the same kind that is being reviewed) is assigned to review the claimant’s treatment. The provider reviews the medical records, the claimant’s statement, the treating provider’s statement and authoritative medical literature. The reviewer can deem all, part or none of the reviewed medical treatment as reasonable, necessary and related as defined by Pennsylvania’s Workers Compensation Act http://www.pacode.com/secure/data/034/chapter127/subchapCtoc.html .
Prospective medical treatment (future medical treatment) can also be subject to a utilization review. In this case, even an injured worker can ask that treatment which is being proposed can be reviewed to ensure that it will paid by the workers compensation insurance company.
The party who is adversely affected by the reviewer’s decision can ask a workers compensation judge to review the determination. It is best to have a lawyer from the beginning of the your workers compensation case to make sure that this process runs as smoothly as possible. Rankin & Gregory can help, call for a free consultation.