Utilization review is a process in workers’ compensation cases where insurers evaluate medical treatment requests. These reviews aim to determine if a particular treatment is necessary.
If you get hurt on the job, and your doctor suggests a specific treatment, your insurer will send a request to a utilization review agent. An independent medical professional then reviews the request to confirm if the treatment is appropriate. The purpose of this process is to ensure you receive the right medical care while controlling costs.
If the reviewer approves a treatment, you can receive coverage for it. If the reviewer denies the request, you might need to appeal or adjust your treatment plan. Utilization reviews can apply before, during, and after you receive your care.
The Utilization Review Process
The utilization review process starts when your doctor requests approval for medical treatment. The insurer sends this request to a utilization review agent—a trained medical professional who conducts the review. This professional follows specific guidelines to evaluate whether the treatment is necessary. They typically assess medical records and treatment plans as part of the review process.
Only licensed healthcare professionals can approve treatment requests, and only clinical peer reviewers can deny requests based on medical reasons. Clinical peer reviewers must have expertise in the same medical field as the treating doctor who suggested the treatment. These review agents must provide decisions within a set time, usually five business days.
If an agent approves your request, you can proceed with your treatment. If they deny it, you can appeal the decision or work with your doctor to modify your treatment plan.
Types of Determinations in Utilization Review
In utilization review, the review agent evaluates a treatment request and makes a determination that directly affects your access to treatment. Below are the key types of determinations:
- Approval: The review agent approves the requested treatment, allowing you to proceed with your doctor’s treatment suggestion.
- Adverse Determination: The review agent denies the request, finding that the treatment is not medically necessary. Only clinical peer reviewers can issue denials based on medical reasons.
- Final Adverse Determination: A treatment denial is upheld after an internal appeal. If this happens, you could pursue external appeals, such as through an independent medical review.
- Modified Determination: The review agent approves part of the requested treatment but reduces or modifies coverage for other parts.
- Delayed Determination: If the review agent does not provide a decision within the required timeframe, the delay could result in a denial, which you can then appeal.
Appealing an Adverse Determination After a Utilization Review
You can appeal the decision if a utilization review results in an adverse determination. The first step is to file an internal appeal with the insurance company. Your doctor can submit additional medical evidence to support the treatment request. The insurance company must review the appeal and respond within a specific timeframe.
If the insurance company denies your appeal again, this results in a final adverse determination. At this point, you can pursue an external appeal through New York’s Department of Financial Services. Then, an independent reviewer will evaluate your case to determine if the treatment is medically necessary.
You must submit requests for external appeals within a specific time frame after receiving final adverse determinations. The external appeal decision is typically final and binding, though legal action might still be an option in some cases.
How a Utilization Review Lawyer Can Help
A utilization review lawyer can assist you throughout the entire review process. Your attorney can ensure that your medical treatment requests are properly submitted and supported by solid medical evidence. They can also communicate with the insurance company and confirm that its utilization review follows New York’s legal guidelines.
If your utilization review results in a denial, your lawyer can guide you through both internal and external appeals. A lawyer can also handle negotiations with insurers, preventing delays in necessary treatment. Obtaining legal support from an experienced attorney is the best way to protect your rights and increase your chances of getting the care you need.
Contact a Utilization Review Attorney Now
If you’re dealing with a workers’ compensation claim or utilization review in New York, contact Fusco, Brandenstein & Rada, P.C. today. Our team can explain your rights and fight for the coverage you deserve. Call the New York workers’ compensation lawyers of Fusco, Brandenstein & Rada, P.C. at 516-496-0400 or contact us online for a free consultation. Let us help you move forward with your case and get the care you need.