What is Utilization Review and How Does it Affect My Claim?

If you have suffered a work related injury, you may have received a letter from the insurance company that a medical procedure and/or treatment recommended by your workers’  compensation doctor has been been sent to their “UR” Department for review.  You may be asking what is “UR”? UR or Utilization Review is when the insurance company sends a copy of your doctor’s recommendations along with your medical records to one of their doctors who has never seen or treated you,  for review to determine if the requested treatment/procedure is reasonable and/or medically necessary.  Of course, Insurance Companies use utilization review to delay or obstruct treatment which has been ordered by the authorized treating physician (ATP).

You may be wondering how this affects you and your workers’ compensation claim.  First and foremost, if the treatment is not denied altogether or in part, it certainly delays your treatment while the review is in progress. Moreover,  the doctor(s) reviewing your medical records may not be in the same state as you or even licensed to practice in your state but they are contracted by the insurance companies to review your records and provide an opinion regarding the necessity of treatment without ever even examining you. This creates unnecessary delay and harm to your health and your workers’ compensation claim.  It is important to contact an experienced workers’ compensation attorney to prevent this unnecessary delay.

This unnecessary delay contributed to the death of an injured worker in California.  In a recent California claim, Sedgwick (the insurance company) agreed to a settlement of over one million dollars for their utilization review practices which resulted in an injured workers’ death due to delay in treatment.  Because of the insurance company’s delays, the injured worker developed a staph injection that would not respond to antibiotics.  The injured worker subsequently died from cardiorespiratory arrest, respiratory failure and pneumonia which resulted from delayed treatment of the infection. In a statement released by Sedgwick, they stated “…the most important port of our statement is Sedgwick’s commitment to ensuring injured workers receive the best possible care when they need it so they are able to return to full health and productivity.”

While this settlement was in California, make no mistake that the same thing happens in other states including Georgia and that Sedgwick is not the only insurance company to utilize the services of physicians to “review” your records to determine whether the treatment recommended by your doctor is “reasonable or necessary”.    We see this in many cases and fight to get our clients the treatment that has been recommended by the their treating physician.

If you have been injured at work and the insurance company is denying your treatment.  Do not wait until it is too late.  Contact the Law Office of Laura Lanzisera and let us help you get the treatment that you need and deserve in a timely matter.