When you make a workers’ compensation claim, you can generally expect the insurer will cover all of your medical care related to your injury or illness. According to the Pennsylvania Department of Labor and Industry, your insurer may request a utilization review of your medical care.
This review examines the treatment you’ve received to assess if it aligns with accepted medical standards and treatment guidelines. The results can influence what care is approved and what may be denied.
If a utilization review has affected your access to medical care or delayed your claim, our team of Western Pennsylvania workers’ compensation attorneys at Luxenberg Garbett Kelly & George P.C. can help. We can review the details of your case, challenge denied treatments, gather medical evidence, and represent you during the appeals process. Contact us at (724) 658-8535 today to schedule a consultation and learn how we can protect your rights and help move your workers’ compensation case forward.
What Is a Utilization Review?
A utilization review is a process used by insurance companies and healthcare providers to evaluate the necessity, efficiency, and appropriateness of medical services. It helps control healthcare costs and ensure patients receive medically necessary care based on clinical guidelines and evidence-based practices.
Types of Utilization Reviews in Workers’ Compensation
Utilization Review (UR) plays a crucial role in managing workers’ compensation claims in Pennsylvania. It assesses the necessity and reasonableness of medical services provided to injured workers. Understanding the different types of UR can help workers and employers alike comprehend how medical care is evaluated and potentially contested.
- Prospective Review: This type of review occurs before a medical service is provided. Prospective reviews primarily focus on the pre-authorization of treatments. For example, if a doctor recommends an MRI for an injured worker, the insurance carrier must approve this procedure before it is undertaken. This preemptive step helps manage costs by preventing unnecessary or excessive medical treatments.
- Concurrent Review: This is conducted as medical care is being delivered. This ongoing process ensures that the treatment an injured worker is receiving remains necessary and appropriate for as long as it continues. It is particularly relevant in cases requiring lengthy hospital stays or extensive rehabilitation programs.
- Retrospective Review: After medical services have been provided, retrospective reviews assess their appropriateness and necessity. This review typically follows the submission of medical bills to the insurance carrier. It serves to verify that the treatments were necessary according to the medical guidelines and were performed as claimed by the healthcare provider.
Each type of UR is governed by Pennsylvania workers’ compensation law, which mandates these reviews to ensure that medical care is both necessary for the worker’s recovery and cost-effective. The outcomes of these reviews can significantly impact a worker’s compensation case, influencing the coverage of medical expenses and the continuation of care. For any discrepancies or denials that emerge from these reviews, workers have the right to appeal, a process that can benefit from legal support to argue effectively for the coverage of necessary treatments.
Understanding these reviews and their implications can be crucial for anyone involved in a workers’ compensation claim, ensuring they are prepared for potential challenges that might affect their case and medical care coverage.
| Type of Review | When It Occurs | Purpose |
|---|---|---|
| Prospective Review | Before the medical service is provided | To pre-authorize treatments and prevent unnecessary or excessive procedures |
| Concurrent Review | During the delivery of medical care | To ensure ongoing treatment remains necessary and appropriate |
| Retrospective Review | After the medical service has been provided | To verify the treatment was necessary and performed as claimed |
What You Can Do During a Utilization Review
If your insurer requests a utilization review, you should receive a notice confirming the request has been filed. While your healthcare provider is typically responsible for submitting medical records and treatment justification, you may be able to submit a personal statement if invited. Carefully review any paperwork you receive, as it may include important deadlines or instructions. If the utilization review results in a denial of treatment, you have the right to challenge the decision by filing a Petition for Review with the Pennsylvania Bureau of Workers’ Compensation.
How a Utilization Review Can Affect Your Medical Care and Benefits
A utilization review may lead to a finding that certain treatments are not considered necessary for your work-related condition. While the review is underway, any bills for the treatment in question are typically placed on hold. Payment is delayed until a final decision is issued.
If the review determines the treatment was not reasonable or necessary, the insurer may not be required to cover the cost. However, Pennsylvania law generally prevents healthcare providers from billing you directly for services denied through the workers’ compensation system. That said, access to prescriptions or additional treatment related to the care under review may be temporarily paused until the process is completed.
A utilization review may put some things on hold until the final determination. The insurer makes the request for this process and pays for it if the insurer feels there is something questionable about the treatment you receive. You are not responsible for the cost of the review and are not required to take action unless you decide to contest the outcome.
How Will a Utilization Review Affect My Case?
A utilization review can affect your case by determining whether your medical treatments are covered by insurance. If treatments are deemed unnecessary or not aligned with guidelines, coverage may be denied, which can delay care or require appeals. The review can impact the approval, timing, and cost of your treatment.
If a utilization review is creating challenges in your workers’ compensation case, getting legal guidance can make a difference. Our team at Luxenberg Garbett Kelly & George P.C. understands how these reviews work and how to respond when treatment is denied or delayed. We can help you protect your access to care and pursue the benefits you’re entitled to. Call us at (724) 658-8535 to schedule a consultation and learn how we can support your claim.
| Type of Review | When It Occurs | Purpose |
|---|---|---|
| Prospective Review | Before the medical service is provided | To pre-authorize treatments and prevent unnecessary or excessive procedures |
| Concurrent Review | During the delivery of medical care | To ensure ongoing treatment remains necessary and appropriate |
| Retrospective Review | After the medical service has been provided | To verify the treatment was necessary and performed as claimed |
