UTILIZATION REVIEW IN SAN DIEGO, CA FOR WORKERS’ COMPENSATION
The Utilization Review process is complex and has many variables. Unfortunately, many employers and insurance companies put more emphasis on keeping money in their pockets than helping injured workers heal. Having an experienced workers’ compensation attorney on your side can make all the difference when it comes to receiving the medical care you need to recover. At The Law Office of Matthew Russell, we’re committed to helping San Diego’s injured workers get the treatment they need and the benefits they deserve.
We’ll do the same for you. Call us at (619) 544-1506 for a free consultation today.
SAN DIEGO, CALIFORNIA UTILIZATION REVIEW FAQS
WHAT IS A UTILIZATION REVIEW?
A Utilization Review (UR) is an independent review of the medical treatment recommended by your doctor. It is the process that employers and claims administrators use to approve or deny medical treatment (including physical therapy) for a worker’s job-related illness or injury. If your doctor recommends treatment that falls outside medical treatment guidelines set by the state, the Utilization Review may result in the denial of your workers’ compensation claim.
DO I HAVE TO HAVE A UTILIZATION REVIEW?
Yes. The State of California requires that every request for medical treatment must go through the Utilization Review process. This applies to all medical treatment and all workers’ compensation cases. Read more on UR Labor Code 4610.
WHAT ARE THE STEPS IN A UTILIZATION REVIEW?
First, the treating doctor sends a request for authorization (RFA) to the claims administrator. The claims administrator can approve the request or send it on to Utilization Review, where an independent doctor approves, modifies, or denies the request for treatment.
WHAT IS AN RFA?
An RFA is a request for authorization of medical treatment. The RFA must include a diagnosis, the type of treatment requested, the state guidelines for the treatment (found in the MTUS), and documentation for why the treatment is necessary. The RFA is sent by the treating doctor to the claims administrator.
WHAT IS THE MTUS?
The MTUS, or Medical Treatment Utilization Schedule is the set of California’s Utilization Review regulations. It contains guidelines and rules for determining the necessity of medical care as well as the extent and scope of the treatment. These guidelines were developed by the American College of Occupational and Environmental Medicine (ACOEM).
WHAT IF MY DOCTOR DISAGREES WITH THE MTUS RECOMMENDATIONS?
If your doctor disagrees with the MTUS treatment recommendations, he or she must provide strong evidence to support an alternate treatment plan to cure or relieve your illness or injury. This treatment plan must be based on peer-reviewed scientific and medical evidence regarding the treatment’s effectiveness for your condition.
WHAT IF MY INJURY OR CONDITION IS NOT ADDRESSED BY THE MTUS?
If your injury or condition falls outside the scope of the MTUS guidelines, your doctor must base his or her treatment recommendations on evidence as outlined above.
UTILIZATION REVIEW TIME LIMITS
The claims administrator has 5 working days to complete the UR process. After five days, a denial is considered invalid. At that point, the insurance company can approve the treatment or ask a judge to review the request and make the decision. If the claims administrator requires additional information before making the decision, they can have up to 14 days.
UR DENIAL WORKERS COMP
If the UR results in a denial of the proposed medical treatment, your best option is to work with a workers’ compensation attorney who can help you appeal the decision via process of Independent Medical Review (IMR) by which an injured worker can make the workers’ comp carrier pay for medical treatment denied by UR.
CONTACT US IF YOUR UTILIZATION REVIEW IS DENIED IN SAN DIEGO, CA
If treatment is denied or reduced, we will analyze the UR decision along with the doctor’s request and fight to obtain the medical treatment for you, appealing the decision and taking the decision to court, if necessary. If you feel you have been unjustly denied medical treatment by a Utilization Review, call our San Diego team of lawyers at The Law Office of Matthew Russell for a free consultation.