Utilization Review in PA Workers’ Comp Pertains Only to Physician or Provider Named, Unless Providers Acting Under Same Physician
In PA Workers’ Compensation, when the workers’ comp insurance carrier feels the treatment rendered to an injured worker is no longer “reasonable” or “necessary,” the relief is for the insurance company to file for Utilization Review (UR). When a UR is requested, the PA Bureau of Workers’ Compensation randomly assigns a Utilization Review Organization (URO) to review the treatment and decide if it is “reasonable and necessary.” Once a UR is requested, until treatment is found to be reasonable and necessary, the workers’ comp insurance carrier does not have to pay for the treatment under review.
When a UR is requested, the workers’ comp insurance carrier must specifically state both the provider under review and the treatment being challenged. A UR only pertains to the provider named, and the treatment as issue. In other words, if a UR finds treatment with a specific orthopedic surgeon not reasonable or necessary, the workers’ comp insurance carrier no longer is responsible for the treatment of that doctor; however, that does not mean the workers’ comp insurance carrier is not responsible for treatment with a different orthopedic surgeon. The workers’ comp insurance carrier would have the obligation to file another UR request, and the process would start all over.
But, what if the provider is not a physician at all, but a physical therapist working under the direction of a physician at the same facility? This was the issue presented to the Commonwealth Court of Pennsylvania in MTV Transportation v. Workers’ Compensation Appeal Board (Harrington).
In this case, Ms. Harrington injured her neck and lower back when she was involved in a car accident while doing her job. As part of her treatment, Ms. Harrington was getting physical therapy. The physical therapist who rendered the treatment was acting under the supervision of a physician at the facility, who was the doctor prescribing the treatment. The workers’ comp insurance carrier filed for UR, naming the therapist who was directly providing the treatment. This led to a finding that the treatment with that named therapist was unreasonable and/or unnecessary.
Ms. Harrington then started treating with a differed therapist at the same facility, working under the direction of the same physician. The workers’ comp insurance carrier then argued it did not have to pay for this treatment, since it was rendered under the guidance of the same doctor, at the same facility. In the resulting litigation, the Workers’ Compensation Judge (WCJ) disagreed with the workers’ comp insurance carrier, and said a UR is only binding on the provider named in the UR request, so treatment with another therapist is not barred by that UR determination. On appeal, the Workers’ Compensation Appeal Board (WCAB) affirmed.
The Commonwealth Court of Pennsylvania disagreed, but affirmed anyway. The Court found that the workers’ comp insurance carrier could have requested a UR by naming the doctor prescribing physical therapy and the facility where the injured worker received that therapy. Had the workers’ comp insurance carrier worded the UR that way, the Court would have found the treatment prescribed by that physician to be unreasonable and/or unnecessary, regardless of which therapist was actually rendering the treatment. However, the workers’ comp insurance carrier instead named only the therapist who rendered the treatment. As such, the Court agreed the UR only pertained to that therapist.
Note that this decision, arguably, pertains only where the injured worker is getting treatment at a facility where the physical therapist, and the physician who prescribes the treatment, both work. In other words, this decision may not be applicable where a doctor prescribes therapy and the injured worker finds a physical therapy facility having no relation to the prescribing doctor.