Utilization Review - It's More than Saying "No"
June 18, 2007

Since the enactment of SB 899, there have been two constant complaints from those who would roll back the system to where it was just a few short years ago. These complaints are the level of permanent disability benefits and the utilization review process used by insurers and employers. It is the latter that drives the entire system, and it is time for critics and regulators to take a closer look at the consequences if utilization review is scaled back.

SB 899 and prior legislation had as their main goal the timely delivery of quality medical care. That is why the recent adoption of a medical treatment utilization schedule is such an important milestone in the implementation of these reforms. Now, the medical community and, hopefully, workers' compensation judges will have clear guidance on what is appropriate treatment and how to go about securing it for injured workers. The consequences to the worker and the employer if these guidelines are not followed are significant - including not getting necessary treatment while disputes languish before the Appeals Board, and the loss of temporary disability benefits before the worker is able to return to work. Delays are costly, but not all delays are due to inappropriate review of treatment requests.

Recently, our claims professionals successfully defended against an effort by a medical provider to obtain payment for over $10,000 in self-procured medical treatment. No attempt to obtain authorization for these treatments was made by the provider. This occurred even though the worker's employer had worked with us to implement a medical provider network (MPN). In this case, we held firm and prevailed. Other incidents with other insurers with other providers before other judges could produce different results. This unfortunate practice continues because there are still providers who will try to get around the new guidelines and judges who will allow it to happen.

Implementation of the medical reforms in SB 899 requires the active cooperation of providers and judges. Utilization review begins with a dialogue between medical professionals and, within tight timeframes, should end with approved treatment that facilitates the worker's recovery and return to work. It does not begin with a medical provider's filing a lien for payment at the Appeals Board for treatment not recognized as appropriate in the medical treatment utilization schedule. If utilization review is allowed to become an obligation falling solely on insurers and employers, it will never produce its desired result.