We have discussed the Utilization Review (UR) process many times in this blog. Indeed, UR is such a big issue in the world of Pennsylvania workers’ compensation that we have a section on our website devoted to just this topic. Basically, UR is the tool used by either an injured worker, or the workers’ compensation insurance carrier (usually the latter) to determine whether medical treatment is “reasonable and necessary.”
A somewhat related process is that for Fee Review. Since this is something that is done by healthcare providers (rather than the injured worker), we have rarely addressed Fee Review in this blog. The healthcare providers often have their own legal counsel handle these matters (rather than obtaining relief through the efforts of the injured worker’s attorney, as in other areas of workers’ comp). Fee Review is the means a healthcare provider uses to obtain payment for reasonable and necessary medical treatment, related to the work injury. Recently, the Commonwealth Court of Pennsylvania issued a decision which dealt with both Utilization Review and Fee Review.
In Keystone Rx LLC v. Bureau of Workers’ Compensation Fee Review Hearing Office (Compservices Inc./AmeriHealth Casualty Services), the injured worker hurt his left knee. As part of the treatment for the knee, the physician ordered medications, which were dispensed by Keystone Rx LLC. The workers’ compensation insurance carrier filed for Utilization Review of the treatment rendered by the physician, including these prescriptions. A Utilization Review Determination found all treatment of the physician, including the medications, to be unreasonable and unnecessary. This meant the insurance company was not responsible for payment of the treatment found unreasonable and unnecessary (including the prescriptions).