Utilization and Review

[1967eagles]

I have been in a workmans comp case for over ten years now,and have seen most everything that could be involved with these cases. The new situation im dealing with now is a UR of my providers. I have has a previous UR of providers and everything turned out in my favor. This recent UR was of three providers and the result was two of them came out positive for me but the third result was not. It was found that medical care was not reasonable due to provider not proving records. I actually called and talked to UR company and was confirmed that they did not do review because records finially came through without providers verification. I am inprocess ofcontacting provider to find out what happened. My first question is since it was a negative result based on no review actually taking place can insurance company use this to not pay provider? Actually I know they can but has anyone seen them doing it? it seems kind of pointless to try. Secondly would it be advisable to put in an appeal to this since there was really nothing to challenge because review of provider was not done so what would I appeal? lastly one option I was thinking was for me to do a UR of the same provider making sure review actually goes through, since I am 99 percent it would be a positive result. Just wondering if anybody seen this or similiar before and looking for any ideas.
from PA

[Timothy Belt]

I have seen many URs over the years including several with similar facts to yours. The insurance company can and will refuse to pay this provider for the treatment that was under review which probably also includes ongoing treatment. However, if you switch to a different provider for the same treatment, the insurance company would either have to pay that provider or file a UR against the new provider.

An appeal would have to be based upon a procedural issue since the judge would lack jurisdiction to review the treatment without the UR. If you have an attorney, you should ask them to review this possibility. If you do not have an attorney, you should consider getting one.

As to filing your own UR, you could try, but it would probably be thrown out since the treatment has already been subject to review.

[1967eagles]

Mr. Belt thanks for your response. Just a follow up question about changing providers. would I have to file any papers with workman comp board or get a medical necessity ruling to switch? and secondly if provider does not get paid due to UR ruling couldnt they( the provider hospital) file a fee review, and would that almost be the same if I appealled myself?
in PA

Mr Belt also if I did file a UR of my own on same provider it would be the first to actually review treatment since the i/c UR never even got records and a review was never actually completed. Still trying to find out how a major Phila hospital system could not get records in time

[Timothy Belt]

Mr. Belt thanks for your response. Just a follow up question about changing providers. would I have to file any papers with workman comp board or get a medical necessity ruling to switch? and secondly if provider does not get paid due to UR ruling couldnt they( the provider hospital) file a fee review, and would that almost be the same if I appealled myself?
in PA

Mr Belt also if I did file a UR of my own on same provider it would be the first to actually review treatment since the i/c UR never even got records and a review was never actually completed. Still trying to find out how a major Phila hospital system could not get records in time

Assuming this is a PA claim, if you change providers, the new provider would simply bill workers' compensation. Since you are well past the first 90 days, the insurance company has no control over where you treat.

The provider under review could file a Fee Review which they would lose since the treatment has been found to be unreasonable and unnecessary. It is not the same as you filing an appeal, since your appeal would challenge a procedural error resulting in the provider failing to send the records.

If you filed a UR on your own for the same treatment, it would likely be tossed despite the fact that the provider never sent records since there is already a determination that treatment is unreasonable and unnecessary.

[1967eagles]

Mr. Belt,
thanks for your response. In the UR decision I received there is a form to file an appeal. If I file a procedural appeal is it a different appeal form then the one provided? If I did file this would it really help especially since it is my provider is the one at fault?

[Timothy Belt]

Mr. Belt thanks for your response. Just a follow up question about changing providers. would I have to file any papers with workman comp board or get a medical necessity ruling to switch? and secondly if provider does not get paid due to UR ruling couldnt they( the provider hospital) file a fee review, and would that almost be the same if I appealled myself?
in PA

Mr Belt also if I did file a UR of my own on same provider it would be the first to actually review treatment since the i/c UR never even got records and a review was never actually completed. Still trying to find out how a major Phila hospital system could not get records in time

Honestly, if you are trying to do this on your own, you are wasting your time. A layperson simply does not have the skill set to properly present this type of technical argument. If you hire a skilled workers' compensation attorney to handle it, you may have a shot.