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Work Comp RFA and Utilization Review

Hi everyone! Dustin here from lawatyourside.com.

One of the somewhat new bodies of law and something that has created a lot of frustration and confusion for a lot of people is what’s called utilization review. It’s called a UR/IMR process. And what this is, is if you’re treating for work-related injury, your doctor requests authorization from the insurance company, and the insurance company is supposed to look at the doctor’s request, look at the doctor’s report, and make a determination, say “yay or nay” whether they should approve that authorization for treatment or not.

Now, there are a lot of rules that they require to abide by. Generally speaking, they have to make that determination within five days after the request is received. In emergency situations, it may be less. There may be situations where it can be longer, but generally speaking, it’s a five days they have to make that determination.

Now, if they don’t make a determination within five days and notify the doctor, then technically, they didn’t follow the procedural rules, and technically, you can go to court and either get a fine or sanction against them or in some cases get the medical treatment approved. It’s really a newer area of law. It may or may not be constitutional. The constitutionality of it was up on appeal as of a few months ago, and it’s something to be honest with. There’s not a lot of uniformity and consistency amongst even the judges in the workers’ compensation system. So it’s a new area. It’s something that people are really trying to struggle with, really trying to figure out, but the law is very clear that says they have to respond within five days.

Now, a lot of problems many clients have is they are trying to get treatment. The request is sent in and then the treatment is denied, and maybe you don’t really know why. There’s certain medical doctors, agreed medical doctors that have said this treatment should be authorized but now it’s not being authorized. What are we supposed to do now?

So if it is denied, then technically, you’re supposed to go to what’s called the IMR process, the Independent Medical Review. It’s an appeal. You appeal the utilization review’s denial and say, “Well, you got it wrong, you should approve this treatment because this, this, and this” and then hopefully knock on wood that they approve the treatment, but it’s been a real big problem in the workers’ compensation system for a lot of people. There’s not really a clear solution unfortunately, and it just caused a lot of headaches for a lot of people, but it is a reality in the workers’ compensation system right now and it’s something to deal with.

So if you’re going through that process, definitely call an attorney to see how they can help out with it and help you get your treatment authorized.

If you want further assistance with your work-related injury or you want to talk to a lawyer and get your questions answered or you want us to represent you in your workers’ compensation case, please fill free to give us a call at the number below or click the link below and fill out the submission form, and we will do our best and work our hardest to ensure that we give you all the benefits that you are entitled to under the law. And we hope you have a smooth, efficient case that runs through, so you can get back to your healthiest that you can be and also receive all the benefits that you are entitled to. Thanks so much.