There are three different kinds of utilization reviews:

1. Pre-certification review — Occurs prior to a medical treatment or procedure
2. Concurrent review — Takes place at the same time the medical procedure is taking place
3. Retrospective review — Happens after the treatment has been completed

Utilization review is a process that your employer’s workers’ compensation insurance company, or a workers’ comp claims administrator, uses in order to decide if the medical treatment your doctor has prescribed for your work-related injury is medically necessary.

In Pennsylvania, if an insurance company requests a UR, the state bureau of workers’ compensation will choose a neutral, third party medical professional to evaluate your condition and decide whether or not the treatment is necessary. A utilization review and Independent Medical Examination (IME) can be requested at any time under the PA Workers’ Compensation Act. This process can be used to determine whether any or all of your medical treatment continues to be necessary.

What happens after the Utilization Review?

Three things can typically happen after a UR has been completed:

1. Medical treatments for the injured worker are necessary and the insurance company will continue to cover the costs.
2. Medical treatment is not necessary and the insurance company is not responsible to pay the costs.
3. Some of the treatments are approved and some are not.

If your treatments were approved and recognized as necessary then everything will proceed as it has been. If it was determined that some or all of your treatments were unnecessary and you disagree with the findings, you can file a petition to have your case re-examined.

The Utilization Review process is complicated and has strict deadlines that must be adhered to for the review and for filing a petition to have a case reviewed. Speak to your Philadelphia Workers’ Compensation attorney here at Larry Pitt & Associates immediately to get advice and guidance about whether pursuing an appeal to the outcome of the UR is worth the effort and expense.

If you have received a serious work-related injury, contact the Philadelphia workers’ compensation attorneys at Larry Pitt & Associates to discuss your case. We have helped people throughout Berks, Bucks, Chester, Delaware, Montgomery and Philadelphia Counties through the UR process for more than 30 years.