You might think that you’ll automatically be granted workers’ compensation to help offset your medical costs and lost wages after a workplace accident. But that would be a mistake. The truth is that insurance companies regularly seek to have claims denied or payment amounts reduced, which threatens to put injured workers like you in a difficult position. One way this occurs is through utilization review.
What is a utilization review?
When you seek workers’ compensation benefits, your doctor’s findings and recommendations will be reviewed by a utilization doctor. This is supposed to be a third-party doctor chosen by the insurance company to review your medical records to determine if the findings and recommended treatment are appropriate and medically necessary.
When the utilization doctor renders their decision, they must do so following certain standards. These include:
- Guidelines that are applicable pursuant to California’s Labor Code.
- Whether the course of treatment has been peer-reviewed and has been scientifically proven to be effective.
- Whether the treatment in question adheres to applicable nation-wide professional standards.
- Generally accepted standards in the medical field.
What if the utilization review finds that your doctor is wrong?
If this happens, then you’ll have to appeal your case for an independent medical review. Here, independent reviewers analyze the evidence to determine if the utilization decision was correct. If the result of the independent medical review is agreement with you and your doctor’s course of treatment, then the insurance company will be on the hook for paying for the recommended care. During this process, the review panel will consider the same standards mentioned above.
Fight for the workers’ compensation benefits you need
Securing workers’ compensation benefits is often more of a fight than people realize. This is because insurance companies are aggressive in protecting their finances. So, if you need help building your workers’ compensation case and finding the best way to fight for a fair and favorable outcome, then now is the time to discuss your case with your attorney.