Employees who suffer work-related injuries and illnesses rely on workers’ compensation benefits to help them receive the medical care they need and get financial support while they recover. Eligible employees receive benefits for lost wages and medical bills, which can help alleviate the financial stress from an injury. However, before the injured worker receives the benefits, they must undergo a review process to ensure that the proposed medical treatment is reasonable and appropriate.
Upon filing a worker’s compensation claim, the insurance company responsible for providing the benefits typically conducts a utilization review to evaluate the medical treatment the treating physician recommends. Employers must understand the workers comp utilization review process to effectively navigate the claims process and ensure that employees receive appropriate medical care. Read on to learn more about the workers’’ comp utilization review process.
What is utilization review?
Utilization review (UR) refers to the approval, modification, or denial of medical treatment for an employee injured on the job. In a workers comp utilization review, insurance companies, through a qualified medical professional, evaluate medical necessity against established medical care guidelines to determine whether the recommended treatment is necessary.
Since medical coverage can be expensive, insurers and employers must closely monitor healthcare services rendered to minimize unnecessary and costly treatments.
4-Step Workers Comp Utilization Review Process
The utilization review process mainly involves the treating physician, the insurance company, and the utilization review physician. The UR process typically starts with an injured worker seeking medical treatment for a work-related injury.
The following are the four steps in the workers comp utilization review process:
1. Request For Authorization By The Treating Physician
The treating physician requests authorization for the medical treatment of an injured worker. The treating physician completes a request for authorization (RFA) form outlining the medical treatment they recommend for the injured employee and submits it to the insurance company.
2. Insurance Company Sends RFA For Review
Once the insurance company receives the RFA, the claim adjuster reviews the request to determine if the recommended treatment is necessary. If they do not believe it is, the company sends the RFA to their utilization review company for evaluation by a utilization review physician.
3. Review Of RFA By Utilization Review Physician
The utilization review physician will then evaluate the treatment request based on nationally accepted clinical guideline standards to determine whether the treatment is reasonable and necessary.
The physician may approve the request as submitted, modify the request to a more appropriate level of medical care or deny the request altogether.
4. Utilization Review Physician Communicates The Decision
The decision made by the UR physician is communicated to the insurance company, the treating physician, and the injured worker.
If the proposed treatment is approved, the insurance company will cover the costs related to the workplace injury. If the treatment is deemed unnecessary, the insurer can deny coverage. In case of a denied request, the injured worker can appeal the decision within 30 days from receipt of the request denial.
The insurance company has five working days to approve, modify or deny the treatment request. If a utilization review decision is delayed, it is considered invalid and, therefore, cannot be used to deny treatment.
Is workers comp utilization review required for every workers comp case?
Yes, before an injured employee can receive benefits for medical treatment, the recommended treatment has to undergo a utilization review by an insurer’s reviewing physician.
What’s the duration of the review process?
The duration of the utilization process varies depending on several factors, including the complexity of the medical request, the need for additional information, and the type of review being performed.
However, an RFA review must be completed within five working days from the first receipt of the request. More time is given if additional information is needed to make the decision.
Understand The Workers Comp Utilization Review Process
Understanding the workers comp utilization review process is essential for employers. By ensuring injured employees receive appropriate medical care while controlling costs, employers and insurance companies can promote a healthy work environment while protecting their bottom line.
As an employer, it is essential to work closely with your insurance provider to ensure the utilization review process is fair, transparent, and meets the needs of everyone involved.