Utilization Review

A Utilization Review is a system that determines whether the treatment the doctor has recommended is medically appropriate to treat your work-related injury. The treatment will be accepted, changed, or refused during this phase. Our Stockton workers’ compensation lawyers have been educating people on the Utilization Review process since the inception in 2003. Our lawyers will explain how the utilization process operates, the various forms of Utilization Reviews, and what to do if the workers’ compensation insurance carrier refuses your care after a Utilization Review. To learn more about Utilization Reviews, contact Stockton Workers’ Compensation Attorneys, P.C. 

Who requests a Utilization Review?

Utilization ReviewIf your doctor thinks care is appropriate, he or she will request authorization from the insurance provider, which will start the review process. The reviewer receives the request for permission and decides whether to accept, alter, or reject the requested medication. The decision is based on the principles outlined in Section 5307.27 of the Labor Code, expert opinion, peer-reviewed scientific publications, and accepted medical standards. You, the doctor, and the insurance provider are all notified of the decision. A physician reviewer, non-physician reviewer, or claims adjuster who works for the Utilization Review firm hired by the workers’ compensation policy may complete a Utilization Review. Without a physical examination under certain conditions, non-physician reviewers cannot refuse or change an authorization request. 

Can the treatment be denied after a Utilization Review, and if so, what do you do?

You have the right to appeal if the insurance company refuses the treatment following a Utilization Review. Following a Utilization Review, you would request an Independent Medical Review. After obtaining the Utilization Review decision, you or your doctor have 30 days to request an Independent Medical Review. You may also request an Independent Medical Review if your condition has significantly changed.  

What are the five different types of Utilization Reviews?

There are give five different types of Utilization Reviews:

  • A prospective assessment
  • A concurrent evaluation
  • A retrospective review
  • An expedited evaluation
  • A prior authorization agreement 

A prospective assessment, also known as a pre-authorization, is a Utilization Review performed prior to the request for medical services. Unless there is a request for additional details, the insurance company must complete prospective reviews within five business days. They must provide a decision within 14 calendar days of the request for authorization in this situation. Within two business days, the insurance company must provide a written decision. 

A concurrent review is a utilization review for care during a hospital stay. Unless there is a request for supplementary details, the insurance company must complete concurrent reviews within five business days, and they must decide within 14 calendar days of the authorization request. Written decisions, on the other hand, must be submitted within 24 hours of completing the review.

In some cases, your doctor provided medical services before seeking permission; then, the insurance company will conduct a retrospective review. The insurance company has 30 days from receiving a request to complete a retrospective evaluation. 

An expedited review is a Utilization Review performed for an injured worker whose health is in jeopardy. An expedited examination is often needed when an employee is facing the loss of life, limb, or a significant bodily function. Depending on the employee’s situation, you must do expedited reports in 72 hours or less. If an expedited review is required, the employee’s physician must mark the “Expedited Review” box on the authorization request form. 

Prior authorization is an agreement between insurance providers to approve new care for specific conditions without requiring the submission of a request for an authorization form.

What can a Stockton Workers’ Compensation Attorney do?

It can be challenging to comprehend the Utilization Review process. Stockton Workers’ Compensation Lawyers, P.C. will explain what you need to know about a Utilization Review. We explain how the Utilization Review process works and what to do if the insurance company denies your treatment. We can also help you understand the various types of Utilization Reviews. For more details, contact a workers’ compensation lawyer in Stockton today.