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How Utilization Review Affects Workers' Compensation Cases

Posted on in Workers' Compensation

How Utilization Review Affects Workers' Compensation CasesAfter employees are granted workers’ compensation for their workplace injuries, employers and insurance companies may still dispute what medical services the compensation should cover. Workers want treatments that can help them fully recover and regain a quality of life. Insurers want the most cost-effective option that will adequately treat the injury. The two sides may disagree upon which treatments are necessary and which are gratuitous. The Illinois Workers’ Compensation Act allows employers to seek a utilization review to determine whether the medical treatment an employee is receiving is necessary to recover from the injury.

Utilization Review

According to Illinois law, a utilization review evaluates whether the level and quality of medical care in a workers’ compensation case is efficient and appropriate, based on standard practices for treating the injury. When an employer conducts a utilization review, a medical professional can make his or her decision based on:

  • Independent medical examinations;
  • Nationally accepted standards of care;
  • Reviews of the healthcare professionals in question and the services they provide;
  • Second opinions on the necessary treatment; and
  • Discharge planning for the injury.

Upon completion of the review, the employer may refuse to pay for the medical treatment only if it is determined to be excessive and unnecessary. The employee can appeal the decision to the Illinois Workers’ Compensation Commission but must prove why the treatment is reasonable in order to recover from his or her injury.

Commission Decisions

Though utilization review is a tool for employers in workers’ compensation cases, employees have used it to their advantage when employers deny paying for a service without first conducting a review. For example, the Illinois Workers’ Compensation Commission ruled in favor of an employee in the 2013 case of Parisi v. Gem Construction Co. The employee requested that his workers’ compensation pay for a strengthening program to help him recover from a back injury and return to full-time work. The employer refused to pay for the program, stating that an independent medical examiner had determined that the employee had reached maximum medical improvement. In siding with the employee, the commission said that the employer had not proven that the treatments were unnecessary because it had not conducted a utilization review.

Right to Compensation

It is important to remember that utilization reviews evaluate the appropriateness of treatments, not the cause of an injury. A review cannot preclude you from receiving workers’ compensation for necessary treatments, including emergency services and basic rehabilitation. A McHenry County workers’ compensation attorney at Botto Gilbert Lancaster, PC, can help you receive coverage for the medical treatments you need. Schedule a free consultation by calling 815-338-3838.



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