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What is an Employer Utilization Review?

July 26, 2017

Workers' compensation utilization review process

You’ve filed a workers’ compensation claim, sought medical treatment, and now your employer or company insurance provider is questioning the physician’s recommended care. It’s a frustrating situation many employees face, and when it occurs we always encourage our clients to talk to a workers’ compensation attorney immediately.

When medical treatment has been provided and the bills come through to a company’s insurance carrier, sometimes the insurance provider or employer believes the treatment given was not reasonable or necessary. As a response, a utilization review request is made, which is a determination of whether medical treatment for a work injury was rational and needed. The review is done by an unbiased third-party, also known as a utilization review organization (URO). The third-party independent is typically a physician, surgeon or other health care provider, or sometimes a panel of these professionals. The URO reviews the medical information provided by the employee’s family and doctor and comes to a decision about whether the challenged treatment was reasonable and necessary for the work injury.

There is an opportunity for an employee to provide a personal statement to the URO about why the treatment should be justified, which can sometimes be a way to guide the reviewer to the right decision. Many do not know this is a vital option to use, which is why it’s important to work with a workers’ compensation lawyer to ensure this step can be done.

If the URO declares the suggested treatment was necessary, the medical provider get paid in full. If the employer or the insurance agency continues to deny treatment after the final ruling, then the employee must initiate a medical legal process to continue the trial.

Going through utilization reviews (URs) can be a trying time and it’s important an employee understands the full process and what he/she can do to fight for their case. The workers’ compensation attorneys at Prior, Criner & Edwards Attorneys understand the importance of getting the review approved, and will work with you every step of the way to ensure your medical treatment is reasonable and necessary. Contact our office today so we can get started on your case.