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Utilization Review Under the New Act

One of the changes made to the Act deals with a facet of workers' compensation law known as "utilization review" or "UR" for short. Insurance companies have used utilization reviews to attempt to refuse payment for medical services requested by an injured worker's treating doctor. The process involves the insurance company sending your medical records to be reviewed by a doctor (usually in another state) to rule on whether certain treatments may be necessary. The UR doctor does not interview or examine the injured worker but merely looks at the medical records and proposed treatment and decides whether or not he or she thinks it is necessary. Often, the reviewing doctor is not even trained in the same specialty as the doctor recommending the treatment.

Prior to the recent changes to the Act, UR reports were not considered heavily by Arbitrators and Commissioners – and for good reason. UR reports ignore the subjective complaints and problems of individual patients and adhere to a strict diagram of what is appropriate treatment and what is not..

Now, the Act puts the burden on the injured worker to refute the findings of these utilization reviews. The injured worker must show that a variance from the standards of care used by the UR physician is reasonably required to cure or relieve the effects of his or her injury. The Act also requires that an Arbitrator or Commissioner must specifically address UR evidence in their decisions. They can no longer choose to give them little consideration.

This change will require an injured worker and his or her attorney to litigate medical issues more frequently - costing the injured worker time and money. It will increase the likelihood that a claim will have to proceed to hearing in front of an Arbitrator. It will require an injured worker's attorney to take the deposition of UR professionals which may result in the delay of appropriate medical treatment.

If you have been injured and your treatment has been denied pursuant to a Utilization Review, please contact our office so that we may fight for your right to reasonable medical treatment.

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