Workers Compensation and the Utilization Review Process

Pennsylvania’s workers compensation system allows workers compensation insurance companies the opportunity to challenge medical treatment for accepted workers compensation injuries. The allowed process is called a utilization review.  What is supposed to occur in the utilization review is that the insurance carrier selects a provider, a range of treatment and a type of treatment to have reviewed by an “independent” provider to determine if the treatment being rendered is reasonable, necessary and related to the accepted work injury.  Most times the utilization review is done for treatment which has occurred and is ongoing.  However, a utilization review may be prospectively filed (by either party) to determine if future medical treatment is reasonable, necessary and related to the accepted work injury as defined by Pennsylvania’s Workers Compensation Act.

The reviewing provider makes a decision based upon the medical records, claimant’s statement, treating provider’s statement and the reviewing provider’s expertise. The reviewing provider then decides if some or all of the past or future treatment is reasonable, necessary and related to the accepted workers compensation injury. The party who does not agree with the reviewing provider’s determination is free to file a legal petition to have the case decided by a workers compensation judge.

Although it is best for claimants to have a workers compensation lawyer from the beginning of the case, it is almost necessary to have representation when litigation before a workers compensation judge. Rankin & Gregory have years of experience challenging utilization reviews for their clients, feel free to call for a free legal evaluation.