What is the point of a utilization review for an injured worker?

On Behalf of | Jun 23, 2023 | Workers' Compensation |

A job-related medical issue can be both stress-inducing and expensive for a worker. They may worry about taking time away from their job and about whether their employer will treat them differently if they require a leave of absence or accommodations to keep doing their job. People often worry about loss of income and the possible major expenses involved in securing treatment in the aftermath of sustaining work-related harm.

If there is any positive aspect to incurring an injury at work or getting diagnosed with a job-related health issue, it would be the workers’ compensation coverage that most employees are eligible to receive. Unlike health insurance, workers’ compensation does not make a patient pay for any part of their treatment. However, the coverage that they receive is subject to numerous rules, and sometimes outside parties may require extra effort from an injured worker. For example, it may be necessary to undergo a utilization review when establishing a treatment plan for a work-related medical condition.

What exactly is a utilization review?

Care that is necessary and appropriate given someone’s diagnosis is often eligible for full coverage, which means the worker has no out-of-pocket expenses. However, there isn’t always an immediate consensus about what the best treatment options will be for a specific worker. Utilization reviews help to validate treatment plans. The process involves comparing the treatment suggested by the physician overseeing a worker’s care with the current best practices for specific conditions. The more invasive or experimental the treatment a doctor recommends is, the more likely it becomes to have that recommendation undergo a utilization review.

For some conditions, there’s only one likely treatment option. Someone with an infection caused by a workplace injury will typically require wound care and a regimen of antibiotics. However, there are many medical conditions that may respond to multiple different types of treatments, and there may sometimes be disagreements about the type of care a worker should receive.

A utilization review helps to resolve such disputes so that workers get the best care. Workers who understand the unique rules and requirements that apply to workers’ compensation claims will be better equipped to navigate the claims process and get the benefits they require. Those facing challenging claims may require legal support when applying for workers’ compensation or negotiating what treatment they will receive.

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