What is a Utilization Review for Workers’ Compensation Claims?

Utilization Review for Workers' Comepnsation San Diego.

Whether you work in a warehouse, restaurant or office building, there’s always a risk for injury or illness when performing your job duties. According to the Bureau of Labor Statistics, approximately 2.9 million nonfatal workplace injuries and illnesses were reported by private industry employers in 2015. Over half of these cases involved days away from work, job transfer, or restriction, all of which can impact a worker’s income. Add this to a growing pile of medical expenses, and the financial consequences can be devastating.

The workers’ compensation system exists to protect workers from unforeseen accidents or injuries that occur on the job. Eligible employees receive benefits to cover missed wages and medical expenses, which can greatly reduce the financial stress of recovery. However, there’s a lot that has to happen before those checks start appearing in your mailbox. One of the most important processes in determining eligibility for workers’ compensation is called a utilization review.

What is a utilization review for workers' compensation?

A utilization review is the process an employer or claims administrator uses to determine whether the proposed treatment for a worker’s job-related injury or illness is medically necessary. If the treatment isn’t found to be medically necessary, the workers’ compensation claim may be denied.

Is utilization review required for every workers’ compensation case?

Yes. The California Supreme Court maintains that every medical treatment request in the workers’ compensation system must undergo utilization review. The process begins when the request for authorization (RFA) is first received by the employer, claims administrator, or utilization review organization (URO).

What is a Request for Authorization (RFA) Form?

A request for authorization (RFA) is a form a physician is required to complete in order to request treatment, diagnostic tests, or other medical services for a sick or injured worker. The treating physician must authorize the RFA with a handwritten original signature for it to be legally binding.

Who reviews and makes decisions on an RFA?

Claims adjusters, non-physician reviewers, and physician reviewers are authorized to make utilization review decisions. They can request additional medical information to make a decision, approve an RFA, or discuss medical guidelines with the physician if the requested treatment appears to be inconsistent with guidelines in California’s medical treatment utilization schedule (MTUS).

How long does the review process take?

This depends on the type of utilization review being performed. A decision on an RFA submitted for prospective or concurrent review, which is conducted prior to or during delivery of requested medical services, must be made within five days from the first receipt of the request. More time is allotted if additional medical information is needed to make a decision.

If a utilization review is conducted after the worker has received medical services, the claims administrator has 30 days to make a decision once he or she has all of the necessary information.

What happens if a URO defers a utilization review decision or denies an RFA?

A claims adjuster or non-physician reviewer can defer a decision of an RFA if the employer disputes liability for the recommended treatment or disputes liability for the workplace injury itself. A reviewing physician can deny an RFA if he or she decides the proposed treatment isn’t medically necessary. You have a right to disagree with decisions affecting your claim, and a workers’ compensation attorney can help you fill out the proper forms to file an appeal.

Have you been injured on the job in San Diego and need workers' compensation?

If you’ve suffered a workplace injury or illness and are thinking about filing for workers’ compensation, call us first. At the Law Office of Gerald D. Brody & Associates, we can help you file your initial claim, defend your rights to medical treatment, and fight to make sure you receive the full benefits you’re entitled to.

Contact us today to schedule your free case evaluation.