What Is a Utilization Review in an Alabama Workers Compensation Case?

What Is a Utilization Review in an Alabama Workers Compensation Case?

Many injured workers are surprised when their doctor recommends treatment—such as an MRI, surgery, physical therapy, pain management, or a referral to a specialist—only to be told that workers’ compensation has not approved it.  Often, the reason is something called a Utilization Review.

But what exactly is a utilization review, and how does it affect your workers’ compensation claim?

What Is Utilization Review?

A utilization review is a process used by workers’ compensation insurance carriers to evaluate whether proposed medical treatment is:

• medically necessary;
• appropriate for the injury being treated;
• related to the workplace injury; and
• consistent with accepted medical standards.

Alabama has established detailed regulations governing utilization review as part of its workers’ compensation medical management system (see Alabama Department of Industrial Relations Administrative Code section 480-5-5-.07)

Unlike an Independent Medical Examination (IME), a utilization review usually does not involve meeting with another physician; instead, the review is typically performed by medical professionals who evaluate medical records, treatment recommendations, diagnostic studies, and other documentation.

Why Does Utilization Review Exist?

The stated purpose of utilization review is to help determine whether requested treatment is medically reasonable and necessary.

For example, utilization review may be used when surgery has been recommended; expensive diagnostic testing is requested; extended physical therapy is proposed; long-term pain management treatment is sought; hospitalization is recommended; or treatment continues for an unusually long period of time.

The review process is intended to determine whether the requested treatment should be certified or approved. Alabama’s regulations contain specific procedures governing utilization review, pre-certification, admission review, continued stay review, and appeals.

How Is Utilization Review Different From an IME?

Many injured workers confuse utilization review with an Independent Medical Examination. While both involve review of medical treatment, they are very different.

An IME generally involves:

• an in-person evaluation;
• a physical examination;
• questions about your injury and symptoms; and
• a written report prepared by the examining physician.

A utilization review generally involves:

• review of medical records;
• review of treatment recommendations;
• evaluation of medical necessity; and
• no physical examination of the injured worker.

In most cases, the reviewer never meets the injured worker at all and may not have all of the injured workers’ medical records.

Does the Utilization Reviewer Become My Doctor?

No. The utilization reviewer is not treating you and does not become your Authorized Treating Physician. Your Authorized Treating Physician remains the physician directing your care under Alabama’s workers’ compensation system. The employer generally directs care through the Authorized Treating Physician and approved referrals.

Can Treatment Be Denied Through Utilization Review?

Yes. A utilization review may result in:

• approval of treatment;
• approval with limitations;
• requests for additional information; or
• denial of treatment.

When treatment is denied, the insurance carrier often relies upon the utilization review findings to justify the denial.

Is a Utilization Review the Final Word?

Not necessarily. One of the most important things injured workers should understand is that a utilization review is not the same thing as a court order. All treatment disputes may still be challenged, either pursuant to the Administrative Code, or through the Court system.

Depositions may be needed in this situation, but it would be very rare for the Court to take the word of a doctor who has not examined an injured worker over the recommendation of the actual treating physician.

What Should I Do If Treatment Is Denied?

If treatment recommended by your Authorized Treating Physician has been denied following utilization review, it is important to:

• obtain a copy of the denial;
• determine the reason for the denial;
• keep copies of treatment recommendations;
• maintain copies of relevant medical records; and
• understand what treatment is being disputed.

Not every denial is appropriate, and not every utilization review decision is beyond challenge.

If recommended medical treatment has been denied through utilization review, if your workers’ compensation carrier has refused to authorize care, or if you have questions about your rights under Alabama’s Workers’ Compensation Act, it may be helpful to speak with an attorney experienced in handling work injury claims.

At Powell and Denny, we have spent decades helping injured workers throughout Alabama obtain the medical treatment and benefits to which they are entitled under the law.

If you have suffered a job injury and you have questions about your rights and benefits under Alabama’s workers compensation laws -don’t hesitate to contact and speak with one of the experienced Alabama Workers Compensation and Social Security Disability attorneys at Powell and Denny today for a free consultation. Appointments are available in person, or virtually via Zoom if more convenient.  Powell and Denny would appreciate the opportunity to help.  And remember, there is no fee unless you win.

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