Tuesday, August 23, 2011

30 Days to Contest Utilization Review

30 days to contest Peer Review or Utilization Review denial of treatment.

Pennsylvania residents injured at work or in auto accidents are often confronted with an insurance company suddenly challenging the necessity of certain treatment. Everything is going along fine, the patient is receiving beneficial chiropractic treatment or massage therapy and suddenly the opposing insurance company decides they don't want to pay anymore.

In the PA workers comp arena, the insurance company requests a utilization review with the judge who, in turn, has the treatment reviewed by a Utilization Review Organization (URO) affiliated with the PA Bureau of Labor and Industry.

Car insurance UROs or Peer Review Organzations (PRO) are much more questionable. Because in the car insurance realm the insurance company has your treatment reviewed by a review organization that they have a contract with. Yes, the insurance company is paying the reviewing organization for their input. So how do you think the PRO typically finds? About 95% of the time its in favor of the insurance company...surprise! The review organization wants to keep its lucrative business going, so it is in their best interests to please the requesting insurance company with decisions against the injured person.

In PA workers compensation a Utilization Review Request is the mechanism by which an employer or insurer may challenge the reasonableness or necessity of treatment by a health care provider. Section 306(f.1)(6) of the Act of June 2, 1915; 77 P.S. s. 531(6).

If the provider or employee disagrees with the finding of the utilization review organization, a petition for review by the department must be filed within thirty (30) days after receipt of the report. The department shall assign the petition to a workers' compensation judge for a hearing or for an informal conference under section 402.1. The utilization review report shall be part of the record before the workers' compensation judge. The workers' compensation judge shall consider the utilization review report as evidence but shall not be bound by the report. 77 P.S. § 531(6)(iv)

Section 306(f.1)(6) of the Act sets forth the entire procedure that must be followed by an employer who wishes to contest the reasonableness and necessity of medical treatment rendered by a health care provider as treatment for a claimant's injury. Subparagraph (iv) of Section 306(f.1)(6) establishes the procedure that a party seeking to challenge the findings of a URO must follow. This subparagraph clearly and plainly states that "if the provider, employer, employe or insurer disagrees with the finding of the utilization review organization, a petition for reviewmust be filed within thirty (30) days after receipt of the report." 77 P.S. § 531(6)(iv).

The Courts have determined that the plain language of Section 306(f.1)(6)(iv) indicates that the time period for filing a petition for review of a URO report begins to run from the date the party seeking review receives such notice.  So for treaters and patients who have received negative treatment reviews, you must act quickly to contest the URO or PROs findings.  If you do not, you will be stuck with the decision and lose out on covered treatment.

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