Workman’s Comp Utilization Reviews

Here is a primer on workman’s comp Utilzation Reviews. (based on California Law).(For TOS, RSI, Chronic Pain, MS, MD patients).

Beware this illegal tactic that some insurance adjusters may use to take away your treatment rights.

If your workman’s comp adjuster all of a sudden begins issuing Utilization Reviews (UR’s) that deny your prescribed treatments, watch out! They are starting a campaign to weed you out of the WC system. They have the right to issue a UR every 60 days (State of California Labor Code 4062). When they issue one, you have 10 days plus filing to appeal. Sometimes they may issue them earlier than every 60 days. (May be illegal).

What do you do?
Write a letter objecting to this finding. If you have an attorney, have him file the objection.
Also have your treating doctor write a letter of objection along with supporting documents & related medical evidence.. All before the 10 days lapse.
You then must have your attorney file for an expedited hearing to fight their findings before the WC judge.

What happens if you do not fight the UR?

First your medical treatment that is requested by your treating physician is denied. If you do not object, the requested item is no longer on the table as a treatment option. This might include medications, injections, blocks, physical therapy, etc. Eventually, your treatment options are so limited, that you may be in physical danger.

Other Consequences

Treating physicians may tire of writing letters that they do not get paid for or may want to charge you for them. They may burn out and drop you as a patient. Attorneys do not get paid for the appeal either and may not be on top of this. You must make sure that these letters get done. You have to be the case manager of your medical condition. DOCUMENT EVERYTHING, every phone call, every letter, every denial & delay. Document time of day & day of year.

How to fight UR’s

Read the Utilization Review and look for “lies.” Examine each sentence. “Here is the truth. Here is a lie.”
1. Has the “employer” used a physician that has never examined or talked to you?
2. Has the physician reviewed your records?
3. Is the employer doctor shopping.
4. Is the physician qualified to practice your case?
5. For example, Does the physician used by the UR every practice blocks, injections, pain management?
6. Just because the insurance company says in the UR “no”, go ahead and submit the medication at the pharmacy. You may be surprised that it all gets approved. This is just more of the game! And / or, if you have the money, go ahead and pay it yourself, as long as your work comp doctor advised it, and keep a record of all of the costs, and later, at court, ask the court for reimbursement.

Your attorney may subpoena the records the physician used for his review. (Are there any?)

Write a declaration letter as to what you need. List all of your medications. Many may be left out in their evaluation. What you are doing is creating a paper trail. Documenting what is happening to you.

Go see your treating physician and have him write the objection letter. This paper trail protects you and your family should this denial result in further medical complications for you.

Your attorney can also subpoena the third party records of the insurance adjustor and the entire insurance record. For example, “I held on the line for 2 minutes and the doctor did not come on so I hung up and denied the procedure.” Is this reasonable? The judge will determine. Is there “bad faith” in the way you are being treated? If there is, the judge will sanction the carrier and/or the employer. This is your health for which you are fighting.
You will prevail with persistence!

This is not a legal opinion. Consult your attorney on all legal matters. Consult your physician on all medical issues. This only a warning label that should be on every UR!

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