Utilization Reviews and Illinois Work Comp
When you are hurt at work and need medical treatment, you go through all the proper steps: you go to the doctor or hospital, follow the advice and treatment plan you are given, and you properly notify your employer so that you will receive workers’ compensation benefits. All should be good, right? But unfortunately in many cases there is a further complication—the utilization review.
If your employer questions the medical necessity of your treatment for the work-related injury, a utilization review organization can conduct a review of your past, present and future medical treatments related to that injury. They will make findings as to whether your treatment is reasonable and necessary. The Illinois Workers’ Compensation Commission, when deciding whether your employer’s insurance should be responsible for your bills, will consider the findings of the utilization review along with the other facts and information presented.
So what is the downside to a supposedly impartial review of your medical treatment by a neutral committee of medical professionals? The employee can end up the loser in this process, even if the employee ultimately prevails. Where employers and their insurance companies are involved in making decisions about what is in your best medical interest, and those decisions can affect what treatment you can afford to receive, then there can be a chilling affect on your proper medical care.
This can be true whether the review concerns past, present, or future treatment. Where the treatment has not yet begun, a review that determines the treatment is not medically necessary or appropriate can cause you to not have that treatment. Even though the determination by the utilization review organization may not be upheld by the Commission, you may not want to take the chance. Likewise, you may avoid necessary emergency care if you know that there is a chance that some review board may opine later that the care was not appropriate and you should not be reimbursed. You could lose important time getting help that could in fact be medically important to your health.
Even if the connection between the utilization reviews and employee healthcare may not seem readily apparent in each instance, you have to be suspect of a process that is injected into the important and trusting relationships between patients and their doctors and the decisions that come from that relationship.
It is important to remember that you are not without recourse. Your lawyer can file a 19b petition for an immediate hearing to resolve these issues. Other evidence can be presented to outweigh the findings of the utilization review. Your health is far too important to let this hurdle stand in the way of getting the proper healthcare you and your physician determine is necessary.
We are workers' compensation attorneys that help people with Illinois work injuries anywhere in IL via our statewide network of attorneys. Contact us and we will answer your questions or find the right lawyer for your situation.
