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Workers’ compensation and utilization review

Published on Jan 23, 2019 at 6:34 pm in Firm News, workers' compensation.

Utilization review is an important factor in many Pennsylvania workers’ compensation cases. An employer, injured worker or insurer can make a utilization review request with the goal of determining whether the medical treatment being provided is in fact necessary and reasonable. Once the request is filed, the case will be sent to a utilization review organization. The URO will request relevant medical records and forward the records to a specialized reviewer.

The reviewer will then make a determination regarding the necessity and reasonableness of the treatment based on experience and medical standards. Typically, the reviewer’s decision comes down roughly 65 days following the utilization review request. Injured workers have certain rights they can assert during a utilization review. For example, an injured worker can issue a statement regarding the effectiveness, reasonableness and necessity of the treatments involved. The worker also has the right to disagree with the final determination via petition.

Generally, a no determination indicates that the medical treatment is either not reasonable or not necessary, or both. A yes determination indicates that the reviewer has found the relevant medical treatments both reasonable and necessary given the injured worker’s requirements. In some cases, the reviewer will make a part no, part yes determination, meaning that only some of the medical treatment has been deemed reasonable and necessary.

Workers who have been hurt on the job and have questions about the utilization review process might want to speak with an attorney. Legal counsel with experience in Pennsylvania workers’ comp might be able to help by collecting and organizing evidence to put together a claim. The attorney might also interview witnesses to the event, negotiate with insurers or advocate on the client’s behalf during hearings.

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