“We will ensure the settlement you receive is the best possible — and we are not afraid to go to trial to get it.”
– Attorney Eric Overholt

“We will ensure the settlement you receive is the best possible.”

Understanding the utilization review process in workers’ comp claims

On Behalf of | Aug 15, 2023 | Workers' Compensation, Workers' Compensation Process |

Workers’ compensation covers your medical expenses if you’ve suffered an occupational injury or disease. But this compensation isn’t handed out on a whim. Before insurers can hand out any payments, a claims administrator must first determine if a treatment is medically necessary for you.

In a process called the “utilization review” (UR), the claims administrator will review whether your doctor’s suggested treatment is acceptable. How does this process work, and what can you do if the UR turns down the treatment?

Based on proven medical treatments

As part of the UR process, the claims administrator will refer to California’s medical treatment utilization schedule (MTUS). The MTUS serves as a treatment guideline to ensure that workers receive reasonable and critical care based on scientific evidence. It also has a drug formulary, which provides guidance on appropriate medication and drugs.

If your doctor is advising a specific medical procedure for your work-related injury, the claims administrator will assess it using the guidelines laid out by the MTUS. Likewise, the claims administrator will refer to the MTUS drug formulary if your doctor is prescribing medicine.

The claims administrator will approve your doctor’s prescribed treatment or medicine if it passes the MTUS guidelines. Only then is your company’s insurer allowed to pay for the medical care. If the administrator determines the procedure or medication isn’t medically necessary, the insurer will not provide compensation.

Note that the administrator can deny a request even if your doctor performed the procedure or gave you the medicine.

Contesting UR denials

Even if a UR led to the denial of treatment, you could contest the decision. This could happen in cases where the MTUS can’t specifically address a medical condition because it’s rare. When this happens, your doctor must perform the prescribed medical care in accordance with other treatment guidelines or peer-reviewed studies, per California law.

You can also contest the decision if you can challenge the MTUS’ presumption of correctness. To do this, you’ll have to present scientific medical evidence that a variation from the MTUS guidelines on a specific treatment is reasonably required for your recovery.

If a claims administrator says your treatment isn’t medically necessary, know that you can still challenge the decision. Consider legal options if you plan to contest a UR decision since you’ll have to find expert witnesses who can confirm your treatment’s necessity.