What You Need To Know About Utilization Reviews

Even though you may have an accepted Workers’ Compensation claim and getting medical treatment paid for by the Insurance Company, the Insurance carrier could obtain a utilization review at any time during your claim. There are some insurance companies that obtain a utilization review every time medical treatment is recommended to an injured worker and this could result in delayed injured worker care.

What Are Utilization Reviews?

Utilization reviews are when the insurance company or self-insured administrator hire another doctor or nurse to evaluate whether the services recommended by your own doctor are medically necessary for your specific medical condition.

Allegedly, the goal of such utilization reviews is to reduce costs without adversely affecting the quality of care to injured workers. The insurance companies state it is for monitoring, evaluating, improving and promoting the quality of care and quality of services provided. However, this is not what Cardinal Law Partners’ Workers’ Compensation attorneys have witnessed.

Lawyers from Cardinal Law Partners have helped many injured workers in NC fight utilization reviews performed in their case and have been able to get them much needed medical treatment options that are recommended by authorized treating physicians.

How Can Utilization Reviews Affect Your Claim?

An insurance company can and will usually deny medical treatment based on a utilization review they obtain that has a different opinion from the treating physician. This is when we see utilization reviews come up in an injured worker’s case. However, just because an insurance company denies your care based on a utilization review, this does not mean you are out of luck. This decision can be overturned and usually requires a hearing request to be filed.

The primary reason many utilization review decisions are overturned by the NC Industrial Commission is many insurance companies use out of state doctors and nurses to conduct the utilization reviews. Based on this fact, we can usually get these utilization reviews thrown out or not considered by the NC Industrial Commission. For an out of state physician to offer or to undertake to prevent treatment to an individual in North Carolina is an unauthorized practice of medicine. Therefore, a utilization review can be disregarded by the North Carolina Industrial Commission because arguably the physician providing the opinion is not authorized to practice medicine in North Carolina.

Other reasons the North Carolina Industrial Commission disregards utilization reviews or gave them less weight is because the utilization review physicians have not seen or talked to the patient. Therefore, the treating doctors have more credibility in offering an opinion pertaining to treatment as they usually have seen the patient multiple times. In addition, the out of state physician is not subject to subpoena powers to allow the patient/plaintiff to question them. Therefore, the physician does not testify in the case and the Commission is allowed to disregard or give the utilization review opinion less weight.

If you or a family member has questions about utilization reviews in your Workers’ Compensation claim, contact Cardinal Law Partners today. Our staff is experienced in dealing with utilization reviews and will help you navigate your claim in North Carolina and the surrounding areas. Call (833) 444-4127 to contact us today!