Utilization Review

MEMORANDUM NO. 2019-06

As I’m sure you are aware, the use of utilization review within the confines of an approved medical care plan is permitted by the Workers’ Compensation Commission pursuant to the regulations established within Administrative Regulation Sec. 31-279-10. Outside the confines of a medical care plan, while there is no explicit prohibition on utilization review, the outcome is not binding, and the Commission is not held to an “arbitrary and capricious” standard to overturn a decision. It is, in these cases, the commissioner who makes the final determination as to the reasonableness and necessity of medical treatment.

It has been brought to my attention that utilization review is being used more and more frequently outside of medical care plans. The entities performing these reviews are not holding to the timelines and standards established by the regulations, yet seem to be placing expectations on both claimants and providers that they need to follow the appeal timelines and regulations that they have set. In the absence of a medical care plan, the claimant can simply take an adverse ruling by utilization review to a hearing and have a commissioner determine the reasonableness and necessity of the treatment in question. The extensive use of UR outside of medical care plans is causing unnecessary delays in medical treatment for claimants and placing unacceptable burdens on medical providers. As the providers are led to believe that they must follow UR companies’ appeals processes, they are forced to participate in peer-to-peer reviews as well as submit additional documentation in order to appeal adverse decisions within the timelines established by said entities.

I am aware that many payers use third party vendors to perform their utilization review. It has been, and continues to be, the Commission’s policy that the payer is the party responsible for ensuring the timely and accurate processing of Workers’ Compensation claims. Should you choose to use a third party vendor for your utilization review needs, the onus is on you to ensure that the vendor is aware of the Workers’ Compensation guidelines surrounding utilization review. In order that all parties may respond to a UR decision appropriately, payers MUST advise all parties, in particular medical providers, if the UR is not binding as there is no medical care plan in place.

In short, it is imperative that payers review their utilization review policies and procedures to ensure that they remain in line with the guidelines established by the Workers’ Compensation Commission. In cases where there is no medical care plan in place, subjecting claimants to unnecessary UR and holding them to arbitrary time frames and appeals processes that delay treatment may subject the payer to fines and sanctions for undue delay.

Should you require any additional information on this matter, please feel free to contact my office.