Utilization Review

Workers’ Compensation Lawyers Pursuing Benefits for Chicago Residents

Injuries may prevent employees from returning to work and affect their ability to financially provide for their family. An experienced workers’ compensation attorney can help prove entitlement to medical expenses, as well as other benefits. Injured workers must show that medical services are necessary and that the expenses were reasonable in order to treat or relieve the injury. The employer, or their workers’ compensation insurer, may challenge medical services through various legal methods, including a Utilization Review as set forth in Section 8.7 of the Illinois Workers’ Compensation Act. At Katz, Friedman, Eisenstein, Johnson, Bareck & Bertuca, we help workers fight challenges to their medical care so that they can receive compensation for ongoing treatment. Our Chicago workers’ compensation attorneys have decades of experience battling insurance company tactics that affect a worker’s financial future.

Understand Your Rights Regarding Medical Care and the Utilization Review

According to the Illinois Workers’ Compensation Act, employers have a right to use a “Utilization Review” of an employee’s medical care to evaluate whether the level of care and the quality of their health care services is appropriate. This may include looking at the appropriateness of hospitalizations or office visits. In most cases, the Utilization Review is used to reduce medical expenses by assuming that medical providers will not violate the limitations set forth in the fee schedule by increasing the type and frequency of treatment. In other words, employers may argue that the medical care being given an injured worker is not necessary.

There are different types of Utilization Reviews, depending on whether treatment has already taken place. A prospective review is used to assess whether the recommended treatment is appropriate. A current review looks at ongoing treatment, and a retrospective review takes place using medical information that the treating physician had at the time that the decision was made.

Employers that choose to conduct a utilization review program may only use a program that has been registered with the Illinois Department of Insurance. Upon review, medical treatment may be either certified or denied. If the treatment is certified, treatment proceeds for the injured worker. If the treatment is denied, the claimant may appeal the decision.

There are limitations to a Utilization Review, including the fact that the reviewer determines appropriate treatment by looking only at medical records, rather than the injured worker. In many cases, the review is not conducted locally, and a medical intake of the worker is not performed. Instead, the reviewer’s opinion on whether to deny the medical tests or treatment is limited to the information provided by the insurance carrier. By relying on a skilled attorney, injured workers may be able to overcome this effort to deny or reduce medical treatment.

Discuss Your Situation with a Chicago Attorney Following a Work Injury

Disputing medical treatment through procedures such as a Utilization Review provides employers and workers’ compensation insurance carriers with a potential way to deny access to medical treatment that has been prescribed by a treating physician, often chosen by the worker. At Katz, Friedman, Eisenstein, Johnson, Bareck & Bertuca, our Chicago lawyers represent injured workers during all of the phases of their claims. As skilled job injury attorneys, we understand the challenges posed by the financial stress and physical injuries resulting from a workplace accident. Our team helps injured workers in Aurora, Springfield, Champaign, Rockford, and Quincy, as well as other areas of Cook, Kane, Winnebago, Adams, and Champaign Counties. To set up a free appointment to discuss your situation, call our office at 312-724-5846 or contact us online.