The Injured Workers Puzzle Picture Part 5: Utilization Review

As we discussed in part 4 of this series, insurance companies want injured workers to select a treating doctor from a “Medical Provider Network” (MPN) – all handpicked by the insurance company.

Also, doctors must follow the Medical Treatment Utilization Schedule – which is a guideline of approved treatment in the workers’ compensation system. This master list of appropriate treatment assures that treatment requests are reasonable.

You would think that insurance companies would automatically approve the treatment requests of their MPN doctors if it was withing the Medical Treatment Utilization Schedule – but you would be wrong.

Despite having total control over the doctors that treat you, and assurance that all treatment requests are within specific guidelines, the insurance companies have yet another way to avoid authorizing the treatment – its called “Utilization Review.”

The UR company – which is selected by the employer/claims administrator – reviews only the medical records provided by the employer/claims administrator, and the review may not even be a physician within the same specialty as the MPN physician. In fact, the UR doctor doesn’t even examine the patient.

If UR denies the treatment request, the injured worker has the right to challenge the denial if it was not done within certain strict timelines or is invalid for some other reason.

With all the ways an insurance company can limit or deny legitimate medical treatment, there is no question that they can save money, at least in the short term. But such tactics are short-sighted. For example:

• Medical studies show that the longer it takes to get necessary medical treatment, the higher the risk of other medical complications. 
• Permanent injury and work restrictions could be increased. 
• Employers have to wait longer for their employees to return to production. 

This is just a partial list of the consequences of treatment delays. 

Think about it – in addition to facing the medical and financial challenges after a work injury, the injured worker also must navigate the additional burden of getting the necessary treatment. Another version of “insult after injury.”

Fortunately, the law provides many ways to challenge unreasonable delays and denials and get injured workers back on the road to recovery.

Once the treatment is completed, the injured worker will be evaluated for a permanent disability award.

We’ll cover that in the next segment.

Tom Martin