“Utilization Review” actually sounds rather benign, but it can seriously affect your case. It’s one of the ways insurance companies try to hurt your claim or deny certain medical treatment. The law in Illinois says that the insurance company has to pay for all reasonable medical care that is related to your job injury. Even so, they’ll try to avoid paying if they can.
One way they try to avoid paying for treatment is with an independent medical examination or IME. Whether it’s really independent is up for debate. The way it works is that they choose a doctor who then examines you, reviews your medical records and writes a report about what they think of your injury, treatment, etc. The goal with an IME is to get an opinion that says your injury isn’t job related, or surgery isn’t necessary, or something else that will allow them to deny your claim or treatment.
The Utilization Review is worse. For a UR, you don’t even know it’s happening because the doctor doesn’t actually meet with you. They only review your medical records and then make a decision about whether the treatment is reasonable. You’re probably asking how that’s even remotely reliable. We don’t think it is.
An experienced work injury attorney can act quickly with a trial motion. In most cases we are able to prove that the doctor who examines you in person multiple times has the more reliable opinion. But even when we are successful, it unfortunately causes delay in both your case and your medical care.
It’s crazy to think a doctor who doesn’t know you and has never even met you can make a determination about your injury. But that’s how it works in Illinois. Your best defense is a good workers’ compensation attorney and being upfront and honest with your own doctor.