I just received a Utilization Review. What does that mean?

If you have been injured in Pennsylvania and are receiving workers’ compensation benefits, the insurance company paying those benefits has the right to question the reasonableness and necessity of any treatment provided to you.  In other words, if you have been seeing a chiropractor and the insurance company would like to question whether the treatment you are receiving is reasonable and necessary any longer, they must file what is called a utilization review, or for short, a “UR.”  So, what does it mean once a UR has been filed?

First, we must understand why the legislature provided for this option for insurance companies.  Essentially, if an insurance company wishes to challenge whether a provider’s treatment is useful any longer they cannot just simply stop paying.  Once a claim has been accepted as compensable in Pennsylvania, the insurance company responsible for that claim must pay for any treatment which is related to the work injury, and both reasonable and necessary.  However, it is very important to understand that a utilization review does not review the question of whether treatment is related to the work injury.  For instance, whether a specific surgery is related to a “knee sprain and strain” may be a question of relatedness and not necessarily reasonableness or necessity.  If the injured worker has suffered with knee pain for a long time, and the accepted work injury is a knee contusion (otherwise known as a bruise) the insurance company may try to say that any surgery proposed by a provider would not be related to the work injury.  So, it’s important to understand that a utilization review does not address the issue of whether treatment is related to the work injury.

The purpose of a utilization review is to determine whether the treatment under review is reasonable and or necessary.  An easy example of why a UR is filed is when treatment goes on for an extended period of time.  If someone who has an injured back sees a chiropractor for six months, an insurance company may file a UR to determine whether that treatment is really providing relief to the injured worker.  The process is started by the insurance company requesting that the Bureau appoint a utilization review organization to review particular treatment.  It can be for treatment that has already passed, or treatment going into the future.  Once the request for a utilization review has been filed, the Bureau will assign the file to a doctor who is in the same profession.  Section 306(f.1)(6)(i), 77 P.S Section 631(6)(i) provides that a utilization review of all treatment rendered by a health care provider shall be performed by a provider licensed in the same profession and having the same or similar specialty as that of the provider of the treatment under review.  In other words, the Bureau will assign the UR in our example to another chiropractor.  That chiropractor will then have 30 days to render an opinion as to whether past treatment and or future treatment (ongoing) is reasonable and necessary.  During the time that this UR is being worked on by the reviewing doctor, the insurance company will not have to pay for the treatment under review.  It’s important to keep in mind that only bills that are under review are part of this stay, and any other medical providers and/or treatment are still the responsibility of the insurance company.

There a number of aspects of utilization reviews that are important to keep in mind. First, URs are doctor-specific.  In other words, if a utilization review is filed against Dr. Smith, the injured worker is free to treat with other doctors in that same practice, or another doctor in a different practice, even if the treatment is the same as what Dr. Smith provided.  Further, utilization reviews must be filed within 30 days of receipt of the bills from a provider.  If a UR is filed beyond 30 days from the last billing, it is considered untimely and will be rejected by the Bureau.

Our clients often ask us if the personal statement that is requested by the utilization review organization is important.  In this writer’s opinion it is certainly wise for the injured worker to voice his or her opinion about the treatment.  However, in 15 years of practice I’ve never seen a utilization review even mention the injured worker statement as being important at all.

After the medical records have been reviewed, the UR organization will issue a utilization review determination.  In this determination it will discuss the various medical bills that were reviewed and make a determination as to whether the treatment is reasonable and necessary.  The URO can find past treatment reasonable, and future treatment no longer necessary, or find all treatment unnecessary and unreasonable, or all the treatment reasonable and necessary.  Further, a reviewer may limit the frequency of treatments, however it may not limit the time frame of future treatments.  Snyder v. WCAB (International Staple & Mach), 857 A.2d 202 (Pa.Cmwlth. 2004).  For instance, a UR may not limit treatment to another six months.  If either party disagrees with the utilization review determination, that party must file a petition to review the utilization review determination within 30 days of receipt of the report.  The utilization review petition is then assigned to a workers’ compensation judge, so that evidence can be presented to either affirm or deny the determination.

The interesting thing about a petition to review a utilization review determination is that the burden to prove whether treatment is reasonable and or necessary stays with the insurance company.  In other words, even though the injured worker may have filed a petition to review the UR determination, the burden stays with the insurance company to prove that the UR provider essentially got it right.  Interestingly, most of the time the attorneys for the insurance company simply rely on the utilization review report.  It is then the injured worker who must provide evidence that the treatment found to be unreasonable and unnecessary is actually reasonable and necessary.  This is usually done by presenting testimony from the doctor under review and from the injured worker.  If the doctor whose treatment is being reviewed is willing to testify about the positive aspects of the treatment being rendered, and the injured worker is willing to testify about the positive aspects as well, most workers’ compensation judges will tend to find that the treatment should continue.  If the judge overturns the negative utilization review determination, all of the bills going back to when the UR was first filed must be paid by the workers’ compensation carrier.

One issue that comes up during litigation is that once the utilization review is rendered against the provider (finding treatment to not be reasonable or necessary), the stay on the carrier’s responsibility to pay for medical bills continues throughout that litigation.  Therefore, the provider being reviewed will not get paid for many months.  This raises an interesting conundrum for the doctor who is still most likely treating the injured worker.  However, in most situations the doctor continues to treat the injured worker with the hopes that the litigation will coming down in the doctor’s favor.

Utilization reviews are often filed for unrepresented injured workers and often are not appealed.  Limitations on treatment are mandated by these unappealed utilization reviews and because many injured workers do not know their rights, they simply believe that the insurance company has the right to dictate the frequency and nature of the treatment.  If you have been injured at work and you are not represented, a utilization review is just one of many problems you are likely to face.  Arrange to meet with a certified specialist workers’ compensation lawyer to understand your rights.

Daniel E. McCabe, Esq., is an associate in the law firm of Wolf, Baldwin & Associates, P.C..  He and managing attorney Levi S. Wolf are two of less than 200 lawyers across the state who have been certified as specialists in the practice of workers’ compensation law by the Pennsylvania Bar Association’s Section on Workers’ Compensation Law as authorized by the Pennsylvania Supreme Court.  His practice, located in the firm’s West Chester office, concentrates on the representation of injured workers and medical providers.  He can be reached by phone at 610.436.8300, or by e-mail at dmccabe@wolfbaldwin.com.

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