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What is a utilization review?

You get hurt at work, slipping and falling from a ladder. You break your leg and have serious back pain. You have never dealt with anything like this before, and you can't believe how it changes your life.

Doctors begin treating you, telling you the types of physical treatment you'll need, how therapy can help and what medications you can take. With multiple injuries, you get laid up for quite a while, and so you lose a lot in wages, all while your medical bills increase.

You're hoping it's all covered with workers' compensation. It's clear from the reports that you did get hurt at work, that your injury led directly to some fairly serious costs and that you did not break any workplace rules.

Then they tell you that the treatments need to go through a utilization review. This process got written into law in 2013. What does it mean for you and your rights to compensation?

The goal of the review

The utilization review essentially gives claims administrators or employers the chance to review the treatment doctors give you. The goal is to find out if everything appears to be medically necessary. They have their own medical treatment guidelines, they look at the recommended treatment options that you got from your physician, and then they decide if they are going to approve that treatment.

Clearly, the end goal here is to keep from covering the costs of treatment that is not necessary, that a doctor should not have recommended. This can help to cut down on cases of fraud and ensures that compensation is only given for the exact costs incurred by the accident itself.

Should you worry?

You really should not worry about this process. It happens in every workers' compensation case. The changes to the law in 2013 made it mandatory. No one is putting you in the utilization review because they think your doctor recommended unneeded treatment. This just happens each time a case begins.

This also does not mean you get no treatment at all. It is just a chance to see if the recommended treatment is needed or if there is a better option for you to pursue.

When does the utilization review start?

As soon as the official gets the RFA (request for authorization), the process starts. The official could be a claims administrator, an employer or someone with the utilization review organization (URO).

Understanding the process

Getting injured at work can change your life. You face stress, lost wages, mounting bills, and potential pain and suffering on top of everything else. The best thing you can do at a time like this is to make sure you fully understand the process and your rights.

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Making a false or fraudulent workers’ compensation claim is a felony subject to 5 years in prison or up to $50,000 or double the value of the fraud, whichever is greater, or by both imprisonment and fine.

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