On many occasions over the years, we have addressed the Utilization Review (UR) process in Pennsylvania workers’ compensation cases. This is the process either party, usually the workers’ comp insurance carrier, uses to obtain a determination as to whether a treatment at issue is “reasonable and necessary” such that the insurance company must pay for the treatment.
What is sometimes lost in this abstract analysis is the impact a UR has on real live people. When a Request for Utilization Review is filed by a workers’ compensation insurer, the insurance carrier is immediately relieved of payment of bills for the treatment at issue, unless and until the treatment at issue is found to be “reasonable and necessary.”
Being in business for profit, or at least to make a living, not all providers are able, or willing, to continue to provide treatment once a UR is filed. One of the most dangerous areas this problem hits home is with medications.
Many medications cannot be suddenly stopped without risk of very severe consequences. Yet, when a UR is filed, frequently retail pharmacies will refuse to fill prescriptions, leaving the injured worker without the medication he or she desperately needs.
This is one of those flaws in the Pennsylvania Workers’ Compensation Act that seems so clear, and so basic, that the PA Legislature would have to fix it, right? That is what we keep thinking, but we have thus far been unsuccessful in having this issue resolved. Sadly, it may take widespread media coverage of a tragic event before things are made right.