Utilization Review in a Pennsylvania Workers' Compensation Case

Under Pennsylvania’s workers’ compensation law, a utilization review is a tool usually used by the workers’ compensation carrier to review the reasonableness and necessity of medical care and treatment rendered to the injured worker. It is a way for the carrier to deny payment in order to save money on a claim.

A utilization review can take three forms: prospective, concurrent, or retrospective.

Prospective review is performed prior to the treatment of the questioned medical procedure. This could be in the form of the adjuster needing to pre-certify the payment of the requested treatment. An example would be if the injured worker’s doctor prescribes an MRI, the workers’ compensation carrier would have to agree to pay for it before it is actually performed. Concurrent review is conducted simultaneously with the medical procedure or treatment. The retrospective review is carried out following the treatment or medical procedure in question.

Typically, the most common type of review is the retrospective, which is triggered by the carrier’s receipt of the bill from the medical facility where the treatment was performed. Once a bill is received, the carrier has 30 days to either pay or deny the bill, or alternatively request that a utilization review be performed.

Once the workers’ compensation carrier has determined that they are questioning the reasonableness and necessity of medical treatment, they can request from the Pennsylvania Bureau of Workers’ Compensation that an independent third party known as a utilization review organization perform the review of the treatment method, duration, and reasonableness and necessity of the same. The utilization review organization will be sent all of the treatment notes from the provider under review, be given the opportunity to speak with the provider regarding the treatment, and will then be responsible for writing a report detailing the treatment and whether all or part of it was reasonable and necessary.

The unbiased utilization review organization typically has the same type of physician perform the review as the provider under review. This could be an orthopedic surgeon reviewing another orthopedic surgeon.

The outcome of the utilization review can take three forms. If all of the treatment is found to be reasonable and necessary, the workers’ compensation carrier would be responsible for payment of the bills. If the treatment is found to be not reasonable or necessary, the carrier can refuse to pay for the treatment; however, if the injured worker then files an appeal of that determination, it will go before a workers’ compensation judge to hear evidence and make a final determination. A third option is that some of the treatment is found reasonable and necessary and some is not, and again, the injured worker could file an appeal seeking an eventual ruling that all of the treatment is reasonable and necessary and therefore should be paid for.

As utilization reviews can be complicated and deal directly with your treatment for your workers’ compensation injury, it is a very wise idea to consult with a qualified workers’ compensation attorney to navigate your way through the process.