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What Is Utilization Review for Workers’ Compensation Claims

Utilization Review for Workers Compensation ClaimUtilization reviews for workers’ compensation claims determine whether a claimant’s treatment is necessary and whether it’s covered by the liable insurance provider.

If you are unhappy with the result of your initial utilization review, you have options for appealing. By contacting a workers’ compensation lawyer, you could reverse a denial and receive the treatment that you and your treating physician think is necessary.

What Is Utilization Review? How Does It Work? 

As defined by the California Department of Industrial Relations (DIR), utilization review is a process used by employers and/or claims administrators to determine whether treatment plans are medically necessary.

Utilization reviews prevent workers from receiving treatment that they do not need or isn’t related to their work-related injuries. During the review, the reviewing physician will evaluate the patient’s treatment plan and injuries. Then, they’ll decide whether they agree with the plan in place.

All employers must have utilization review programs. Otherwise, they’re not in compliance with California’s workers’ compensation laws.

How Is Initial Treatment Determined?

After you suffer a work-related injury, you must see a treating physician on your employer’s list of approved care providers. Your visit will be very similar to visiting another doctor under regular circumstances.

A doctor may focus your initial treatment plan on:

  • The cause of your condition
  • How seriously you were injured
  • Whether you have a long-term ailment
  • What it means to recover from your condition
  • Whether you have any pre-existing health concerns, such as diabetes

Your employer, the insurer, and your care provider don’t want you to undergo treatment that doesn’t benefit you. Not only does treatment cost money, but you don’t want to prolong your recovery period longer than necessary.

What Is the Utilization Review Doctor Looking For?

To determine whether a treatment plan is necessary, the doctor must follow guidelines from the state of California and peer-reviewed scientific evidence.

Per the DIR, California has a code of regulations that dictates whether certain medical practices are necessary. These regulations are better known as the Medical Treatment Utilization Schedule (MTUS).

The MTUS is based on the best medical and scientific evidence currently available. It also accounts for the practices and treatments backed by detailed studies.

What Is the Utilization Review Process Like?

Here’s what you can expect from the utilization process after filing your workers’ compensation claim:

  • Your treating healthcare provider will request for authorization (RFA) for medical treatment from the liable insurer.
  • The liable insurer submits the request to utilization review.
  • The utilization review doctor evaluates the treatment request and determines whether everything’s medically necessary.
  • The utilization review doctor sends their decision to the treating provider.

A utilization review determination must be made within five days of an RFA’s submission. If it is not done within this period, then the review is invalid, and a judge can determine if the medical treatment is necessary.

The utilization review could have one of the following outcomes:

It Gets Approved

If your treatment plan is authorized, then the process is over. Your treating doctor can continue with the original treatment plan. Then, the liable insurer should cover a portion of your lost income and the totality of your medical bills.

Your Case Gets Delayed 

If your treatment plan gets delayed, you may have to give the utilization review doctor more information.  You must act in a timely fashion to ensure you get treatment and have your medical bills covered by your employer’s insurance.

The information that the physician needs is outlined in the determining utilization review letter. If you are unsure what to do, you can speak with your treating physician or a workers’ compensation attorney.

Your Treatment Plan Gets Rejected 

If your treatment plan gets rejected, that means that the physician who reviewed your case does not believe it’s necessary or meets the appropriate guidelines. A rejection notice can be alarming, but you have options for appealing.

What Happens if I Receive a Rejection?

A rejection does not mean that you cannot receive treatment; it just means that the reviewing physician thinks your current plan is not the best one. You and your treating physician can amend your treatment plan, or you can file an appeal.

You generally have 20 days from the time that you receive your rejection letter to object to the determination in writing. After filing your appeal, you must wait for a final decision. If you still do not get the result you want, you could request a hearing and have your case heard by a judge.

Why Partner with a Workers’ Compensation Attorney After Getting Hurt?

Your workers’ compensation attorney in Los Angeles has one goal: to secure the benefits you need to move forward from your on-the-job injury. They can guide you through each step of the process, from notifying your employer of your condition to arguing your case at trial. Some benefits of partnering with an attorney include:

  • You protect yourself from any attempts to derail or dismiss your claim.
  • You stay abreast of your legal options and learn what decisions benefit your situation.
  • You give a professional the obligation of managing all case-related communications.

Right now, you deserve to focus your time and energy on healing. With a legal advocate, you can rest easy knowing that your case is in good hands.

Contact KJT Law Group Today for a Free Case Review 

If you were injured at work, and you want to file a workers’ compensation claim, you could benefit from having an Los Angeles personal injury attorney on your side. They can guide you through the claims process, explain specific terminology, and provide peace of mind.

At KJT Law Group, we can help you through the utilization review process, ensuring you follow all deadlines and laws, while also making the correct decisions for your health. Should you receive a rejection, our workers’ compensation lawyer can advocate for what you need. If you want help before, during, or after the utilization review for your workers’ compensation claim, call us at (818) 507-8525.

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