What is a Workers Compensation Utilization Reviews?
Los Angeles Attorneys Explain
Workers Comp Utilization Reviews or “URs” –
Under California Workers’ Compensations law, any and all requests made by an injured worker’s treating physician for medical treatment have to go through a “utilization review” (UR). This is a review process aimed to ensure that the requested treatment is considered “medically necessary” – before it will be approved.
All employers – or their workers’ compensation claims administrators – are required by California Workers Compensation law to have a “utilization review” (UR) program that is used to decide whether or not to approve medical treatment recommended by a worker’s treating physician.
The California Supreme Court has held that only reviewing physicians may decide to delay, deny or modify treatment requested by an injured employee’s treating physician. Additionally, to reduce the cost of physician review UR, an employer is also allowed to implement a “prior authorization” program within the employer’s UR plan – which more or less allows for “pre-approval” of some conditions/treatments (without needing a UR).
Types of Workers Comp Utilization Review (UR)
The process for utilization review can be complicated, and can take many forms. Our Los Angeles Workers’ Comp attorneys have helped thousands of men and women navigate the reviw process and obtain the mediocal treatment they need.
Below we have listed some of the different types of Workers Comp utilization review processes you may encounter. Howver, the best way to understand how the UR system – and any aspect of the workers’ comp process – applies to your unique situation is to discuss your case with an experienced Los Angeles Workers’ Compensation attorney.
Workers Comp Prospective Review
A prospective review refers to a UR (Utilization Review) that is conducted BEFORE the delivery of the requested medical services. Note: in California, the terms “prospective review” and “pre-authorization” mean the same thing. (However they are different from “prior authorization”.) A written decision must be sent within two business days for prospective reviews.
Workers Comp Concurrent Review
A concurrent review refers to a UR (Utilization Review) that is conducted for treatment that takes place during an inpatient hospital stay. A written decision must be sent within 24 hours for concurrent reviews.
Workers Comp Retrospective Review
A retrospective review refers to a UR (Utilization Review) that is conducted AFTER medical services have been provided that have not been previously authorization. Retrospective reviews are required to be completed within 30 days of receiving the information required to make a decision.
Workers Comp Expedited Review
An expedited review refers to a UR (Utilization Review) that is conducted when the injured worker faces an “imminent and serious threat” to his or her health. This may include situations involving the potential loss of life, limb or other major bodily function. Expedited review can also apply when the regular time-frame for approval would be detrimental to the injured worker’s life or health, or might jeopardize the injured employee’s permanent ability to regain maximum function. Expedited reviews must be completed within 72 hours – or less if the injured worker’s condition warrants a shorter time-frame.
Workers Comp Prior Authorization
Prior authorization refers to a specific arrangement written into the UR plan that sets forth specific conditions or circumstances under which a specific treatment is guaranteed to be approved – without submitting a request before, during or after the treatment. In other words, if an employer has Prior Authorizations in a UR plan, approval is “automatic” for these conditions/treatments.
Workers Comp Attorneys Can Help with Utilization Review
Our experienced Long Beach Workers Compensation attorneys are here to help you with all aspects of your California Workers Comp Case – including your Utilization Review (UR). Our experienced lawyers would be happy to discuss your unique situation with you, to ensure that you receive the medical treatment you need – and the maximum workers compensation benefits for which you may qualify.