Utilization Review (UR)/Independent Medical Review (IMR) – Denials of treatment
Denied medical treatment is front and center in the workers’ compensation debate regarding whether injured workers’ are treated fairly. The purpose of the system was to provide timely medical care and get injured workers back to work quickly. Our legislators, with the help of the insurance companies, have created a system where injured workers suffer denial after denial without meaningful ways to appeal. This leads to delays in treatment or no treatment. The injured worker is unable to improve leading to the inability to return to work for long period of time, or in many cases, unable to return to the job. Insurance companies then blame the injured worker for not returning to work quickly.
There are some steps you can take to ensure that the insurance carrier does not have the ability to deny treatment based upon a technicality. Make sure your primary treating doctor is making all treatment requests on a Request for Authorization (RFA) form. If treatment is not being authorized, but you have not received a Utilization Review (insurance carrier hires company to review all medical treatment requests) denial in the mail, it is likely your doctor did not make a proper request or send the request to the proper place.
It is best to select doctors that are familiar with the guidelines used to determine appropriate treatment. This cuts down on the number of denials.
The Utilization Review (“UR”) decision must be issued within 5-14 days depending on whether additional information was requested to make the decision. There are many rules for a UR decision to be valid and an attorney currently has a right to go to court to fight invalid denials that are untimely. Attorneys who specialize in workers’ compensation should understand what makes a valid UR denial and which should be challenged in court.
If a UR denial is received, your primary treating doctor has 10 days (depending on the UR company) to perform a UR appeal to the UR company. Your best chance of having the denial overturned is to have your doctor perform this appeal.
All UR denials must be sent to you with paper work, filled out, to help you prepare an appeal to Independent Medical Review (“IMR). This is the next level of appeal above UR appeals. You only have 30 days to file this appeal. It is the insurance companies obligation to send relevant records to IMR for review. There are many rules to what makes a valid IMR appeal and you should ensure your attorney is be familiar with those rules. The reality is most of the IMR appeals follow the UR denials but appeals can be successful in certain circumstances.
The unfortunate truth is that most valid UR denials are upheld by IMR during the appeal process. These treatment denials will remain denied for 12 months, but there are exceptions.
The changes in the law have significantly impacted injured workers’ right to obtain medical treatment. This 2013 legislation has pushed too far in allowing insurance companies the right to deny reasonable requests for medical treatment. While we are hopeful that Judges push back and/or legislators see the light, this may take time. We recommend that you work with your doctors to appeal these treatment denials, and if necessary, consult with an attorney that is familiar with these issues.
