What Is a Utilization Review and How Can It Affect My Workers’ Compensation Case?

Before you start receiving your workers’ comp benefits, you must generally undergo several processes, including a utilization review to determine your workers’ compensation eligibility.

According to a recent report, in 2020 alone, there were around 2.7 million work-related injury and illness cases. This number only accounts for cases reported in the private sector. Sadly, most of these cases result in time off work, job restrictions, or even job change. Thankfully, US states have workers’ compensation systems that offer employees financial support to help ease their financial pain due to work-related illnesses or injuries.

However, before you start receiving your workers’ comp benefits, you must generally undergo several processes, including a utilization review to determine your workers’ compensation eligibility. So, what is a utilization review? And why is it important?

What Is a Utilization Review?

A utilization review is a process through which an employer or the insurance company reviews the proposed medical treatment plan to determine whether it’s medically necessary. The treating doctor proposes a treatment plan for your injuries, but your employer or insurance company will only pay for your treatment once they’ve conducted an independent review of the treatment plan.

Who Reviews and Makes Decisions on a Utilization Review?

The insurance company, your treating doctor, and non-physician reviewers are generally authorized to make decisions regarding utilization reviews. They can request additional medical information from your doctor to make decisions or further discuss medical guidelines to determine whether the requested treatment is consistent with Missouri’s standards of care.

“My Treatment Plan Was Denied”:  Now What?

You have a right to appeal a denied treatment plan. The process for appealing a denied treatment plan is generally as follows:

• File a claim with the Missouri Division of Workers’ Compensation. Once you have filed the claim, a conciliation meeting is scheduled between you, the division representatives, and your employer’s insurance company to review both sides of the case and determine the validity of both arguments.
• Next, you’ll need to prove that you were injured while on the job and that any medical expenses in dispute were for necessary treatment.
• Based on the evidence presented, the insurer may or may not be ordered by the court to cover your medical bills.

St. Louis Workers Compensation Lawyer

Going through a utilization review is no easy feat. You will bvenefit from working closely with an experienced workers’ compensation attorney who can present your case and ensure your rights are protected. The Law Office of James M. Hoffmann has over 30 years of experience and has successfully represented injured workers in the utilization review process. We can do the same for you. Call us today for a free case evaluation.