Utilization Review for Injured Auto Workers

Chicago Lawyers for Workplace Accident Claims

Medical expenses are a significant part of workers’ compensation claims. Insurers believe that sometimes workers try to get issues treated through workers’ compensation that are not related to their work injury. In order to combat this phenomenon, insurers sometimes use what’s known as utilization review. Utilization review is a process whereby medical services and treatment are reviewed to determine whether the worker has received appropriate care for their injury. Nationally recognized guidelines are applied in the utilization review process to look not only at a proposed treatment plan, but also the care that has already been given, the scope of services provided, and how long these services lasted. Utilization review for injured auto workers can be complicated, and a seasoned Chicago workers’ compensation attorney at Katz, Friedman, Eisenstein, Johnson, Bareck & Bertuca can represent you during that process and in all other aspects of your claim.

Utilization Review for Injured Auto Workers

Section 8.7 of the Illinois Workers’ Compensation Act covers how utilization review should be used. Under this section, utilization review is an evaluation of proposed or previously provided health care services to determine whether the level of health care services deemed medically necessary were appropriate, and also assess the quality of the services given to a patient. The quality of services may be gauged using factors such as how effective the treatment was, how efficient it was, how appropriate it was, and to what extent it met certain standards.

An evaluation should be done through a system that identifies health care services based on a standard of care of nationally recognized peer review guidelines, as well as nationally recognized treatment guidelines. The medical care should be evidence-based.

Techniques used in utilization review may include not only prospective and retrospective review, but also independent medical exams, peer review, second opinions, concurrent reviews, and discharge planning. An experienced workers’ compensation lawyer can help you through the steps involved in this process.

Submitting to a Utilization Review Program

A utilization review program needs to be appropriately registered with the Illinois Department of Insurance. Medical providers treating auto workers injured on the job are supposed to submit to the utilization review process if the insurer or employer invokes it. After receiving notice that it has been invoked, the doctor or other provider is supposed to follow accredited procedural guidelines for utilization review.

A provider is supposed to make a reasonable effort to give a timely report of the clinical information that’s needed to support the auto worker’s request for treatment. When a provider doesn’t do this, the charges for the treatment may not be reimbursed by workers’ compensation. To balance this, however, the provider’s reporting obligation is not supposed to be unreasonable.

Treatment Denials

Under Section 8.7, an employer can only refuse to authorize or pay for medical services that have been provided or recommended to the extent that those services would be unnecessary or excessive according to an accredited utilization review program. When a utilization review denies treatment, the injured worker has a very challenging burden to overcome. He has to prove it is more likely than not that deviating from the standards of care used by the person conducting the utilization review is reasonably necessary to provide relief from the impact of the injury or to cure it.

Sometimes, in spite of the outcome of the review, an employer or insurer may authorize treatment, since a claimant is entitled to depose the person who conducted the utilization review. The cost of deposition and interview are supposed to be paid by the employer.

Chicago Attorneys for Workers’ Compensation Claims

If you need representation due to a utilization review as an injured auto worker in Chicago, the dedicated workers’ compensation lawyers of Katz, Friedman, Eisenstein, Johnson, Bareck & Bertuca serve clients in Springfield, Quincy, Rockford, Aurora, and Champaign. We also represent injured workers in Kane, Cook, Winnebago, Sangamon, Champaign, and Adams Counties. We will look closely at your case to assess whether other relief, such as damages in a personal injury lawsuit or SSDI, may also be pursued. Call us at 312-724-5846, or contact us online to learn more.