There are times in workers’ compensation matters where attorneys on both sides are bewildered when reviewing a utilization review (UR) decision denying requested medical treatment, especially when the denial substantially increases the value of the permanent disability entitlement to the injured worker. Twice we have seen this done over the past few months.
The first case involved an injured worker who weighed more than 300 lbs. The worker needed surgery but only if performed safely. To assure that, the worker would first need to lose 60 lbs. A supervised weight loss program was requested for the worker but denied by UR. As a result, the worker was unable to undergo surgery. He was then rated “as-is” at 100% instead of 40%, which was the anticipated rating had he undergone surgery. UR ended up saving the company $750 by denying a weight loss program, only to increase PD from 40% to 100%, a difference valued at $1.25 million.
In our second example, physical therapy for a back injury was denied by UR even though therapy was recommended by both the PTP and a QME. The QME thereafter reported a substantial 40% PD because without therapy the injured worker was unable to recover. Had it been approved PPD would have only been 10%.
These are just two examples where the claims adjuster should step in and override UR, providing such action is not prohibited by company policy. Some administrators do not allow adjusters to override UR because management does not wish to deal with an employer or reinsurer who raise angry questions over such action. As a result, many administrators do not override UR only to substantially increase the value of PD far beyond the medical savings.
Here at Friedman + Bartoumian, we are available to discuss questionable UR denials with our clients to help determine if the decision should be overridden. By analyzing projected UR savings and comparing them to the anticipated increased value of PD, a recommendation can easily be ascertained. In addition, a defense attorney recommendation usually satisfies any concerns raised by employers and reinsurers. Lastly, if requested treatment is denied by UR, we can assist in identifying a substitute treatment plan so that the injured worker is not left without alternatives. The last thing any administrator wants to do in any of their claims is to repeat the two examples mentioned in today’s blog!
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