What Is Utilization Review?

In Illinois, workers may receive medical treatment and other benefits for job-related injuries. But employers and insurance companies also have the right to assess that treatment. One means of evaluating treatment is utilization review. What is utilization review?  Let GWC Injury Lawyers explain.

Utilization Review: Evaluating Patients Without Seeing Them

Since 2005, the State of Illinois has allowed employers and insurance companies the right to request a utilization review. Section 8.7 of the Illinois Workers’ Compensation Act defines utilization review as follows:

The evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards.

Medical professionals conducting utilization reviews do not even meet with their patients. They simply review their medical records and determine whether their treatment is reasonable, sometimes even from another state.

If the utilization review results in the denial of treatment, it places an additional burden on the employee:

When a payment for medical services has been denied or not authorized by an employer or when authorization for medical services is denied pursuant to utilization review, the employee has the burden of proof to show by a preponderance of the evidence that a variance from the standards of care used by the person or entity performing the utilization review…is reasonably required to cure or relieve the effects of his or her injury.

How a Workers’ Compensation Lawyer Can Help You

As you can see, insurance companies can take advantage of utilization review to create significant obstacles for injured workers who desperately need medical treatment. When this happens, hiring an experienced workers’ compensation lawyer could mean the difference between receiving a necessary procedure or an unjust denial.

A knowledgeable attorney can question the medical professional who conducted the utilization review under oath. Such in-depth questioning may cast doubt on the review’s conclusions, which could be very costly to the insurance carrier and put pressure on it either to approve the treatment or settle the claim under more favorable terms.

For this reason, if you get injured on the job, consider retaining the services of the dedicated workers’ compensation attorneys at GWC Injury Lawyers LLC.

GWC is one of the premier Workers’ Compensation and Personal Injury law firms in Illinois. With over $2 billion recovered on behalf of our clients and more than four decades in the business, GWC has the experience you need to get you the compensation you deserve.

Contact GWC today to schedule a no-cost, no-obligation consultation with one of our workers’ compensation lawyers. You may call us at (312) 464-1234 or click here to chat with a representative at any time.