Utilization Review

Massachusetts Workers’ Compensation Attorneys

The Massachusetts work injury lawyers at Kantrovitz & Associates pride themselves on providing individualized service and personal attention from our office in downtown Boston. With over 20 years of experience, we are happy to explain utilization review and its role in the workers’ compensation system. We have recovered benefits for numerous workers in Massachusetts, New Hampshire, and Rhode Island.

What is Utilization Review?

When a worker suffers a job-related injury, the employer’s insurer must review the requested treatment and health services provided to the employee. During utilization review (UR), insurers or their agents look at various factors regarding the delivery of medical care, including:

• Proper costs of service
• Quality of care or treatment
• Requests for medical expenses
• Review before or after procedure
• Whether service is “appropriate and effective”
  • Defined as “medically necessary and reasonable”
  • Determination based on objective, clinical findings

Insurers and approved agents must conduct UR using certain procedures approved by the Office of Health Policy (OHP), a division of the state Department of Industrial Accidents (DIA). Requests for medical expenses must be processed through UR prior to rendering care. Otherwise, the insurer may deny the requested medical procedure or subject the treatment to post UR analysis.

UR Procedure and Determination

UR agents follow a specific procedure in determining whether the service is “appropriate and effective” or “medically necessary and reasonable.” A licensed medical reviewer will render the final determination according to the DIA’s health care services treatment guidelines. The agent then sends a letter of approval or “adverse” determination that includes:

• Clinical rationale for determination
• Relevant section of treatment guideline
• Instructions to appeal adverse determination
• Start and end dates for all scheduled health services
• Notice within 2 days from request for service in prospective review
• Notice within 1 day before start of ongoing service in concurrent review
• Notice within 20 days from request for rendered medical care in retrospective review

UR agents must provide written instructions describing how to appeal an adverse determination. An injured employee may initiate the appeal, which is conducted by the UR agent, by calling the agent, but should follow-up with a written request. An appeal must be received within 30 days of an adverse determination. UR agents have 2 days to render a decision in most appeals, but have 20 days to adjudicate an appeal of retrospective reviews.

UR Quality Assessment and Appeals

The OHP monitors UR agents for compliance with Massachusetts General Laws (MGL). Failure to comply with the relevant rules and regulations may result in probation, fines, an order to cease and desist, or revocation of the agent’s license. After appealing an adverse determination by the UR agent, injured workers may also file a complaint under MGL c. 152 § 10. The DIA and Review Board adjudicate medical disputes and other issues involving workers’ compensation.

Workers’ Compensation Benefits

At Kantrovitz & Associates, our Massachusetts workers’ compensation attorneys have guided injured employees through countless UR procedures and appeals. We understand the review process, including the insurers, agents, and other actors who make decisions about your health care. We have obtained approval of requested medical services for injured workers in Boston, Essex, Norfolk, Suffolk, Middlesex, Plymouth, and Merrimack counties, among others. Call 800-367-0871 today for a free consultation or contact us online.