What Is a Workers’ Comp Utilization Review?
Just because your workers’ compensation benefits have been granted does not automatically mean that all of your medical treatment will be covered by the insurance company. If you are having any difficulty with your claim, even after you have received benefits, the workers’ compensation attorneys at Heiting & Irwin can help.
The insurance company will make a determination about whether they will cover certain medical treatment, but they are constrained by public guidelines and laws issued by the state. In fact, there are very strict requirements that an insurance company must follow when deciding whether a treatment is medically necessary through a process called a utilization review. Even so, you have legal options if the insurance company decides they will not cover your care.
Call the workers’ compensation attorneys at Heiting & Irwin when you are experiencing any difficulties with the insurance company or if you need any other help with your claim. We fight every day for injured workers to receive everything to which they are entitled under California law.
The Insurance Company Must Cover Appropriate Medical Care
When you are receiving workers’ compensation benefits in California, the insurance company must cover reasonable and necessary medical care to treat your injury. However, just because your treating doctor says that certain medical treatment is necessary does not mean that the insurance company will automatically cover it. Instead, they will conduct a workers’ compensation “utilization review” to decide whether treatment is “medically necessary.” The results of this review could determine whether you need to fight to get the medical treatment you need.
Under California law, each claims administrator is required to have a department to conduct utilization reviews, so they can decide whether to cover recommended medical treatments. These departments cannot simply make their own decisions based on their own opinions. Instead, they must utilize guidelines issued by the state to determine the “medical necessity” of your treatment. Claims administrators must follow a strict set of rules in carrying out this process, or else they may face tough penalties from the state. California will even conduct routine investigations of claims administrators to determine whether they are following the rules.
What Is Subject to a Utilization Review?
Not all medical care goes through a utilization review. California law exempts emergency medical treatment (on a body part that has been accepted by the employer as compensable) from a utilization review, so long as the treatment occurs within thirty days of the initial injury. However, there are a number of things that must be prospectively reviewed by the claims administrator within 30 days after your injury, including:
- Pharmaceuticals
- Medical equipment
- Non-emergency inpatient and outpatient services
- Imaging and radiology services, such as MRIs (but excluding x-rays)
- Home health care treatment
- Psychological treatment
Your treating doctor will need to submit a request for authorization of your medical treatment before it occurs. Otherwise, he/she may lose the right to be your treating physician.
The claims department must then use procedures that have been developed with input from actively practicing physicians and consistent with the schedule for medical utilization. In other words, an insurance company cannot simply introduce its own more stringent restrictions because they want to deny more medical care. The claims administrator must give the claim consideration, subject it to review, and a “prompt answer” to any request for medical care, issuing their decisions within 14 days after it has been received. The claims administrator could respond by:
- Allowing the claim and approving the treatment
- Denying the treatment
- Modifying the request to either partially approve the request or substitute their own recommended treatment
What Happens if Your Medical Treatment Is Denied?
Although their decisions should be consistent with state guidelines, it does not always work out that way. Thankfully, the insurance company does not get the final say about what care they will cover; and if the insurance company will not cover your care, you have the right to request an independent medical review or a qualified medical examiner appointed by the state, and they can reach their own determination about your entitlement to the treatment. You can also file an appeal with the Workers’ Compensation Appeals Board and get a hearing in front of an objective administrative law judge. It is beneficial to have good workers’ compensation attorneys like Heiting & Irwin (Richard Irwin is a certified specialist in workers’ compensation and has been for over 25 years!). However you address a denial of your care, you should consider hiring a workers’ compensation lawyer to fight for you to get the medical treatment you need and to help you recover physically and financially from your injury.
Contact the Riverside Workers’ Compensation Law Firm of Heiting & Irwin
Speak to the Riverside workers’ compensation lawyers at Heiting & Irwin when you need an advocate and fighter during the legal process. You can reach out to our workers’ compensation attorneys by calling us at 951-682-6400 or by messaging us through our website.
