We have discussed the role of Utilization Review (UR) both on our website and on our blog. This helps demonstrate how important this concept is in the Pennsylvania workers’ compensation system. As the Bureau’s Workers’ Compensation Automation and Integration System (WCAIS) takes an increasingly bigger role in the practice of workers’ comp in PA, there are changes which must be made. One of those deals with the UR process.
UR is, of course, the process to determine whether a given course of medical treatment is reasonable and necessary. If treatment is found to not be reasonable and necessary by the Utilization Review Organization (URO), the workers’ comp insurance carrier is not liable for the payment of that treatment (nor, by the law, is the patient). A determination by a URO can be appealed to a Workers’ Compensation Judge (WCJ).
Typically, a UR is initiated by the workers’ compensation insurance carrier, to try and avoid paying for a specified medical treatment. Frequent targets in these URs are physical therapy, chiropractic treatment and medications. However, there are often situations where we file a UR, prospectively (for some future treatment), so our client can more easily get a specific treatment, whether it be a diagnostic study (such as an MRI or EMG), surgical procedure, or unusual medication.