Long term medical care related to workplace injuries can be a costly and frustrating proposition for employers and/or their Workers’ Compensation insurance carriers.  In many cases, the injured workers’ medical care continues far beyond the point where they are otherwise deemed physically fit to return to work.  When an injured worker returns to work after recovering from an injury, the employer’s obligation to continue to pay for reasonable and necessary medical care does not necessarily end.  So, how is an employer and/or Workers’ Comp carrier supposed to keep that ongoing medical care in check?  The answer is simple, but the strategy for when to employ the process is a bit complicated.

The Utilization Review process is an integral part of Workers’ Comp practice and procedure in Pennsylvania.  Like many other states, PA uses the UR process as the sole method available for employers and their Workers’ Compensation insurance carriers to formally question or review ongoing medical care for an injured worker.  The UR process is available to all employers, and can be used for any type of medical care, at any time.

The strategy for determining when to use the UR process is a bit complicated.  Using the right strategy for when and why to use the UR process is important because the process itself can be costly (the employer and/or carrier must pay certain costs associated with an independent medical review), and of course, the benefit of the UR process is the tens of thousands of dollars in savings that can come from avoiding unnecessary, ongoing medical care.

In terms of the strategy – there are three basic types of medical care that seem to cry out for a UR:  First is what can be generally referred to as “excessive care.”  When an injured workers’ treatment has exceeded the point where it appears to be useful, the UR process should be used to formally question any care beyond that point or date.  Without a medical degree or a crystal ball, how can this be determined?  The answer is simply, common sense.  When an injured workers’ medical care reaches the point where an average person would begin to question its benefits, that is the point where the care can be questioned through the UR process.  For example, when an injured worker visits his/her chiropractor twenty times per month for a year – with no end in sight – the UR process can allow the employer the ability to question, and ideally put an end to, the ongoing chiropractic treatment.  Another common example of “excessive care” is ongoing prescription medication.  In many cases, injured workers will remain on a prescription drug regimen, without interruption, for years.  This type of ongoing medical care can cost tens of thousands of dollars, depending on the type and/or number of prescriptions.  Again, the UR process allows the employer and/or the insurance carrier the opportunity to seek a formal review of the ongoing prescription medication, to obtain an independent determination regarding whether the prescriptions continue to be useful, and necessary.

The second type of medical care that calls out for a UR is the “experimental treatment.”  For decades, the health insurance industry relied on the tagline of experimental treatment to justify denials of payment for medical care.  In the current world of Workers’ Compensation, the idea that some medical care is simply too far-fetched to be deemed “reasonable, necessary and related” is alive and well; the UR process gives employers and carriers the ability to question/deny payment for this type of experimental care.  Typical examples of this care include some things that are arguably not even commonly known as traditional “medical care” such as: fitness club memberships, waterbeds, orthopedic chairs, orthopedic shoes, etc.  These items or recommendations can be part of a treating physicians’ regimen for an injured workers’ care, but that does not necessarily mean that the Workers’ Comp law will protect the injured workers’ right to get this “care” paid for by his/her employer or Workers’ Compensation insurance carrier.

The third most common type of medical care that demands a UR is the intervening/unrelated care.  The UR process can be used by employers and/or carriers when an injured worker continues treating for a work-related injury, while the person is also treating for another, unrelated medical issue.  Often, work injuries occur to individuals who are already treating with a doctor for an unrelated issue or chronic pain condition.  It is also common to see intervening/unrelated injuries occur to individuals who are already treating for work-related injuries.  In either case, it can be very difficult to determine whether ongoing medical care – particularly prescription medication, physical therapy and/or chiropractic care – is reasonable, necessary and related to the work injury (and not something else altogether…).  The UR process gives employers and carriers the power to limit their exposure/obligations to only the work related injury, and nothing more.

Using the right strategy, employers can make the UR process work for them, and can avoid long term medical care obligations for injured workers whose treatment has passed the point of efficacy.  In my next blog entry, I will discuss the steps that must be taken to ensure the best possible outcome through the UR process.  Stay tuned…