Getting the Medical Treatment You Need
When a workers’ compensation claim is filed after a work injury, you may be entitled to medical treatment…
If the physician requests medical treatment, the claims administrator may decide to refer the treatment request to a utilization review (UR) company that they select. The UR company can then either deny, modify or approve the treatment request. There are very strict time limits that the claims administrator must follow for the UR to be valid.
How the UR Company Decides To Deny, Modify or Approve Treatment
A UR vendor should be using California’s Medical Treatment Utilization Schedule (MTUS) to decide whether the physician’s treatment request is Denied, Modified or Approved. However, since UR is merely a “paper review” (the patient is not examined by the UR physician, nor does the patient get to send records), the UR reviewer only has the records the claims administrator chooses to forward, and they are often incomplete.
This presents a problem for the UR reviewer because, in order to determine whether the treatment request is appropriate, the UR reviewer must have all the relevant records. Requests are often denied because the UR reviewer is often unaware of the complete record.
The California MTUS is legally required to meet certain scientific standards, but in certain instances, it does not. Because each person is unique, the medical treatment recommended for you may not fit in the MTUS “cookbook” and for that reason, much needed medical treatment may be delayed or denied because of that.
We are often asked: “If I have an Award from the Judge for lifetime medical treatment, am I subject to UR?” The answer is….maybe. If you have a longstanding medical treatment plan in place in the workers’ compensation case, there may be exceptions to UR, but they are rare.
If UR denies your physician’s treatment request, you may request Independent Medical Review (IMR) within the required time limit. If IMR denies the treatment, there are also strict time limits to appeal that decision as well.
We Are Here To Help You
If UR and IMR sound like a huge interference with the treatment your physician wants, that is exactly what it is – second and triple guessing by doctors who haven’t even examined the patient. After all, treating physicians are licensed by the State of California to heal injured workers and get them back to work, if possible.
If your physician’s treatment request is being held up by the claims administrator, UR reviewer or IMR reviewer ( or all three ), you may want to consult with a workers’ compensation attorney to determine whether the denials and delays are illegal.
We are here to help you. Call us 714-547-5025 to discuss your rights.
The consultation is always free and confidential.