Alabama Workers Compensation: What is Utilization Review. If you have suffered a serious job injury, chances are good that at some time you will be told that the test or surgery recommended by your treating physician is “under review.” You are probably wondering “under review for WHAT?”
Alabama law allows the workers’ compensation insurance carrier to conduct utilization reviews (UR) to determine whether to suggested treatment is reasonably necessary given your condition. “Reasonably necessary” simply means that the treatment is reasonable given your condition; not absolute or strict necessity. If the treatment is reasonably necessary, Alabama law states that the insurance carrier SHALL PAY for said treatment. Common sense tells you that the treating physician would not request authorization to perform a test or treatment which the doctor does not believe is reasonably necessary, yet more and more through the past 5 years, workers compensation has used UR as a way to deny treatment to an injured worker.
Utilization review typically works like this. Your treating physician informs you that surgery is needed to repair your job injury. At this time the workers’ comp insurance provider hires a physician in another State to review some of your medical records and state whether the suggested treatment meets the insurance provider’s definition of medical necessity. Not surprisingly, the doctor hired by workers comp often states that the requested treatment does not met this contrived standard, surgery is then denied and you are informed that the surgery is not needed. If this has happened to you, do not let the insurance carrier get away with it.
While no one knows what tomorrow may bring, to date I have not spoken to a single plaintiff or defense attorney in Alabama who has had a UR denial of treatment withstand court scrutiny. The judges know what the definition of “reasonably necessary” is and give little credence to the findings of a doctor in another State who has never seen you and who is not aware of what the standards are in Alabama.
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Alabama Workers Compensation What is Utilization Review