Utilization Review

In Illinois, the Workers’ Compensation Act sets forth your rights and benefits in the event that you suffer a work-related injury or illness. Under the Act, the insurance company is required to pay all reasonable medical care that is related to the workplace injury. The insurance company paying the benefits has the right to request that an injured worker see a physician of their choice for an independent medical examination (IME), which the injured worker is required to attend. As a practical matter, this means the insurance company picks a doctor who then examines you, reviews your medical records and provides an opinion regarding your injury and treatment plan. Many times, insurance companies use IMEs to poke holes in an injured worker’s claim. For example, the physician may opine that the injury is not job related or that surgery is not required.

Utilization Review in Illinois Workers’ Compensation Cases

A utilization review allows a physician to review a worker’s past, present, and future medical care related to a work injury to ensure that it is reasonable and necessary. To be clear, the utilization review assesses the appropriateness of the treatment, not the cause of the injury. In many ways, a utilization review is worse than an IME in that the physician appointed by the insurance company does not even have to examine the injured worker. Rather, the medical professional evaluates whether the level of care and quality of health care services is appropriate in a workers’ compensation case, based on standard practices for treating the injury in question.

Depending on the stage of the workers’ compensation case, there are different types of utilization reviews. A prospective review is used to evaluate whether the recommended treatment is appropriate, whereas a current review examines ongoing treatment. A retrospective utilization review, on the other hand, uses medical information that the treating doctor had at the time their evaluation was made. A medical professional conducting a utilization review can provide an opinion based on the following:

• Independent medical examinations;
• Nationwide accepted standards of care;
• Reviews of the treating medical professional and their services;
• Second opinions pertaining to necessary treatments; and/or
• Discharge planning for the injury.

In reality, insurance companies often use utilization reviews to argue that the medical treatment being provided to the injured worker is not necessary. Upon completion of the review, medical treatment for the injured worker will either be certified or denied. If it is certified, treatment will continue. If it is denied, the benefits will terminate, though a claimant can appeal this decision to the Illinois Workers’ Compensation Commission, and an experienced work injury lawyer can assist with this process.

Diligent Workers’ Compensation Attorneys in Wheaton and Schaumburg

The last thing injured workers need to worry about is the cost of medical care. A utilization review can seriously impact your case. In fact, it is one of the ways an insurance company may try to limit your benefits or deny your claim altogether. At Therman Law Offices, our seasoned work injury lawyers are familiar with the tactics employers and insurance companies use to limit legitimate claims in Wheaton and Schaumburg. We understand how to fight for your rights in these situations. We represent clients from Addison, West Chicago, Lemont, Elmhurst, Westmont, Oakbrook, Terrace, Downers Grove, Clarendon Hills, and Lisle. For more information about your case, please call us at 312-588-1900 or reach us online.