A utilization review, otherwise known as a UR, is when your employer’s workers’ compensation insurance carrier has an outside doctor review your medical records and author a “UR Report” stating whether or not the medical treatment recommended by your treating physician is “medically necessary within Official Disability Guidelines”.
To help you better understand, I’ll give you an example. Imagine you’ve been undergoing treatment for a low back injury that you can’t quite overcome. Despite going through physical therapy, you are still experiencing low back pain. So your doctor recommends that you undergo an epidural steroid injection hoping that it resolves your pain once and for all, and puts you on the road to a full recovery. Instead of approving this minimally invasive conservative treatment, the insurance carrier submits the treatment recommendation and your medical records for a utilization review. That doctor hired by the insurance carrier then reviews your medical records and the request for treatment and determines whether or not that treatment is medically necessary pursuant to the “Official Disability Guidelines,” or ODG, all without ever examining or speaking with you. I should also mention that while this is going on, you most likely will not be notified that your treatment has been sent for a utilization review.
Here’s what you need to know about the Official Disability Guidelines. First, and foremost, the organization who published them, Work Loss Data Institute, has a financial interest in making the guidelines as conservative as possible. The ODG counts employers, insurers, and third party administrator’s as their clients. AKA, the company and not you, the injured worker. On the ODG’s website, they boast that the use of the Guidelines has led to “Medical cost-savings of 25%-60% (by state, payer, TPA, and health plan). www.worklossdata.com This is why the UR report most often ends with “This request is not medically necessary within Official Disability Guidelines…” This gives the insurance carrier the legal basis they need to deny the medical treatment requested by your doctor.
Once the physician performing your UR makes the determination that the treatment recommended by your doctor is not medically necessary, the next step is for the UR doctor to call and discuss it peer-to-peer with your doctor. It essentially provides your doctor the opportunity to argue the necessity of your treatment, and could allegedly change the UR doctor’s determination. However, I don’t think I have ever actually seen one single time where the UR doctor was able to get the treating physician on the phone to discuss their opinion. Most of the peer-to-peer calls I have seen take place at 7:00 am, noon, or even 6:00 p.m. It is an interesting coincidence how those calls almost always take place during a time when the doctor is sure to be unavailable.
As a side note, I’ll tell you a secret. When I did workers’ compensation defense I always recommended against obtaining a UR. Insurance companies like them because they are cheap; much cheaper than a Section 12 exam (commonly called an IME, or independent medical exam). URs are cheap and dependable for the employer, but not very credible in my opinion. In six years, I honestly can’t remember more than a handful of URs certifying, or approving, the recommended treatment. The overwhelming majority of URs deny the medical necessity of the recommended treatment.
Once the recommended medical treatment is denied, you have two options. Accept the decision of the UR report or fight it. In order to fight it, you will need the help of an experienced workers’ compensation attorney who can take the insurance company before the Illinois Workers’ Compensation Commission to present your case. Utilization Reviews are just one example of how insurance companies are trying to cut costs and save money at the expense of the injured worker. Sadly, it results in slowing down an injured worker’s treatment and their eventual recovery.
To learn more about utilization reviews or how we can help you file a workers’ compensation claim, please contact our office by calling us today for a free consultation at 618-252-7422.