Utilization Review: What is It and What Do You Need to Know About It?

Technically speaking, the law pertaining to utilization review can be found in Labor Code Section 4610.  In plain language, utilization review is the insurance company’s review of medical treatment recommendations made by a treating physician for a Workers’ Compensation injury.  The intent is to ensure that recommendations are reviewed by a medical doctor instead of the claims handling examiner who lacks the medical knowledge to make a determination whether to authorize, delay or reject a medical treatment recommendation. Injured workers as well as their physicians will often receive a letter in the mail from a utilization review company and/or physician detailing whether or not a medical treatment request has been authorized. 

The following are things you should know regarding this process and the applicable  timelines:

1. Within five days but no more than 14 days from receipt of a medical treatment request by a treating physician, a utilization review determination should be made as to whether the request is authorized, delayed or rejected.  If the determination is delayed, it’s because additional information has been requested.  It is important to identify in the letter what specific information the utilization review physician is missing so your treating doctor can provide it.

In addition, there is an entirely separate set of complicated utilization and dispute rules regarding requests for spinal surgery.

2. Within 20 days of receipt of a utilization review denial letter, the injured worker or his or her attorney must object to the denial in writing. This creates a “medical dispute” that has to be resolved through the medical legal dispute evaluation process.

3. If the utilization review process is not done in a timely manner, the insurer shall authorize the medical treatment. This was reaffirmed in the California Supreme Court case known as Sandhagan. 

4. This utilization review process applies to cases with future medical awards as well, regardless of the date of injury.

5. Unfortunately, there is no standard form or format upon which utilization review letters are to be created.  Thus, they come in different formats with varying numbers of pages. In addition, they often include standard, boilerplate language that can be confusing.

In order to receive medical care in a timely manner, it is imperative that you are knowledgeable about the utilization review process timelines.
 
If you need more information on how to combat frivolous and wasteful utilization review denials in your case or receive a utilization review denial that is difficult to understand, you should seek advice from a skilled attorney.

The law firm of Gordon, Edelstein, Krepack, Grant, Felton & Goldstein, LLP is dedicated to protecting the rights of those who have suffered serious injuries on or off the job. If you would like to speak with an attorney about your legal options, please call us at 213-739-7000.