Utilization Review Reform Apparently on the Radar of PA Legislation

Back in July, we warned about potential legislation which is being pushed by the Pennsylvania Chamber of Commerce, and PA insurance carriers, to reform the Pennsylvania Workers’ Compensation System. We discussed several areas which we anticipate will be targeted. Proposed legislation is likely to appear in early 2013.

One area we did not mention seems to be getting more traction. That is the process of Utilization Review (UR), the tool either party can use to have a determination made as to whether the medical treatment at issue is reasonable and necessary. As the process now stands, on appeal from an initial UR, a Workers’ Compensation Judge (WCJ) considers the UR determination made by the Utilization Review Organization (URO). The WCJ is not bound by the determination made by the URO. This makes sense, since other evidence is required to determine whether treatment is reasonable or necessary, predominantly the testimony of the injured worker.

The proposal being raised by the insurance industry and the Chamber of Commerce appears to be that the WCJ would be bound by the determination of the URO, effectively making the UR reviewer the ultimate finder of fact, a role the PA Workers’ Compensation Act strictly leaves to the WCJ. Moreover, since the UR reviewer only assesses records, and never actually examines the injured worker personally, the injured worker would effectively be removed from the entire evaluation. This result would be ludicrous, given that whether the treatment relieves symptoms or provides greater function to the injured worker is, and should be, a critical element to determine whether medical treatment is truly reasonable and necessary.

Again, we urge all of our loyal readers to contact their State legislators and make sure they know that protecting the rights of injured workers is in the best interests of all of Pennsylvania’s citizens. After all, none of us has a crystal ball – nobody knows the identity of the next worker to be injured on the job.