Utilization Review

When a workplace injury occurs, access to timely and appropriate medical care is essential for recovery. However, disputes often arise over the necessity or reasonableness of certain treatments, and these disagreements can delay or deny the care injured workers need. Utilization review is a process used in Maryland’s workers’ compensation system to evaluate the medical necessity of treatments and ensure that healthcare provided to injured employees is consistent with established guidelines. While utilization review is intended to control costs and promote quality care, it can also create challenges for injured workers. If you are facing issues related to utilization review in your workers’ compensation claim, you should talk to an attorney about your options. The skilled Prince George’s County workers’ compensation attorneys at Foran & Foran, P.A., can assess your case and inform you of your options for protecting your interests. 

Utilization review is a process in which medical professionals, often employed or contracted by the employer’s workers’ compensation insurer, assess whether the treatment recommended for an injured worker is necessary and appropriate. This evaluation typically involves reviewing medical records, treatment plans, and diagnostic reports to determine whether the proposed care aligns with established medical guidelines. The process can apply to various types of treatment, including surgeries, physical therapy, medications, and diagnostic tests.

While utilization review is intended to ensure that injured workers receive effective care, it can also lead to disputes when an insurer denies or limits treatment based on the review’s findings. For example, an injured worker may be denied authorization for a recommended surgery if the utilization review concludes that less invasive options should be tried first. These denials can delay recovery, exacerbate an injury, and create additional stress for the worker.

The impact of utilization review is particularly significant for workers with complex or chronic injuries. Disputes over the necessity of ongoing treatments, such as physical therapy or pain management, can leave workers without the support they need to maintain their health and quality of life. Understanding how utilization review works and how to challenge unfavorable decisions is critical for ensuring that your medical needs are met.

Under Maryland law, employees injured in the course of their employment are entitled to workers’ compensation benefits, including coverage for reasonable and necessary medical expenses. Utilization review plays a central role in determining whether the treatment proposed for an injured worker meets these criteria. However, injured employees have the right to challenge adverse decisions arising from the utilization review process.

If a treatment is denied following utilization review, the injured worker or their treating physician may request a reconsideration or appeal the decision. This often involves providing additional medical evidence to support the necessity of the treatment, such as updated diagnostic reports, expert opinions, or detailed explanations from the treating doctor. Maryland law also provides for hearings before the Workers’ Compensation Commission to resolve disputes over medical necessity.

Navigating utilization review disputes can be complex, particularly for workers already dealing with the physical and emotional challenges of a workplace injury. An experienced workers’ compensation attorney can help you gather the evidence needed to support your case, advocate for your medical needs, and represent you in hearings or negotiations with the insurer.

In addition to addressing utilization review, injured workers should be aware of their broader rights under Maryland’s workers’ compensation laws. These rights include the ability to choose their treating physician, receive wage replacement benefits, and access vocational rehabilitation services if necessary. Ensuring that these rights are protected is essential for achieving a successful recovery and financial stability.

Utilization review can present significant challenges for injured workers seeking the medical care they need to recover from a workplace injury. If you are facing delays or denials due to utilization review, it is critical to meet with an attorney as soon as possible. The experienced Prince George’s County workers’ compensation lawyers of Foran & Foran, P.A., can evaluate your claim and aid you in gathering the evidence needed to help you pursue the full amount of benefits recoverable. We have an office in Greenbelt, Maryland, and we proudly represent injured workers in Hyattsville, Upper Marlboro, Bowie, La Plata, Waldorf, Rockville, Silver Spring, and throughout Prince George’s County, Charles County, Montgomery County, and throughout the state Maryland. You can arrange a confidential and free meeting with us by using our form online or calling us at (301) 441-2022.