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Understanding a utilization review under workers' compensation

While California workers are protected from long-term loss of income and can be compensated for medical care through workers' compensation if they have suffered workplace injuries, there are always certain underlying aspects that must be accounted for. One is the utilization review (UR). An injured worker will want to be informed about this process and know what to do if it presents a problem for them.

UR is when the claims administrator makes sure that the treatment the injured worker is receiving is medically required. This assessment is not done by choice, but rather is required under the law. The UR is used to decide whether to approve a treatment plan from an injured worker's doctor. There are certain rules as to how the UR is handled. A worker who believes that there was a violation of any kind can file a complaint with the Division of Workers' Compensation (DWC).

There is a treatment guideline to assist with the utilization review, which is known as the medical treatment utilization schedule (MTUS). This schedule was discussed in a previous post. The treatment recommended by a doctor can be evaluated by anyone who handles claims, but a denial or a change in treatment can only be made by a doctor who has a full understanding of the kind of injury or illness the worker has suffered, as well as the recommended treatment.

There are other aspects of a UR, such as the timeframe for which the UR must be completed what to do when treatment has been recommended, what happens when treatment has already been provided, how to deal with disputes about bills and the administrator saying they will not pay for the treatment, and the process of obtaining an expedited review. These will be covered in a subsequent post. In the meantime, those injured workers who are seeking workers' compensation benefits and have concerns about denied claims or issues with UR should make certain they are protected by discussing their concerns with a qualified workers' compensation attorney.

Source: California Department of Industrial Relations, "Answers to frequently asked questions about utilization review (UR) for injured workers," accessed on Sept. 18, 2017

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