‘Utilization review’ is exclusive way to challenge treatment — Business Management Daily: Free Reports on Human Resources, Employment Law, Office Management, Office Communication, Office Technology and Small Business Tax Business Management Daily

‘Utilization review’ is exclusive way to challenge treatment

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The California Supreme Court has ruled that there is only one way for employers to challenge the medical treatment injured workers and their doctors want to pursue. All challenges must use a process created by the California Legislature called “utilization review.”

Recent case: A car struck Brice Sandhagen while he was working as a foreman on a road construction project, injuring his neck and back. Since then, he has been under continual medical care. Sandhagen’s doctors recommended he undergo an MRI test to see whether disc degeneration or herniation was causing his pain. The doctors submitted the test request to the company’s insurer, which sent the request to its doctor.

State legislation designed to expedite medical treatment and control costs requires California employers to use the utilization review process and either deny or approve treatment within 14 days. Sandhagen’s employer missed that deadline.

Then, the employer’s doctor said the treatment wasn’t necessary. The company tried to challenge the treatment through the workers’ compensation hearing process. It argued that the new legislation wasn’t intended to be the sole way for employers to challenge treatment, but was simply another avenue.

But the California Supreme Court said the process found in the legislation was the employer’s exclusive opportunity to challenge treatment, and the deadlines were binding. (State Compensation Insurance Fund v. WCAB, et al., No. S149257, Supreme Court of California, 2008)

Final note: Work with your workers’ comp insurance carrier to make certain it is using the utilization review process. The deadlines are tight. 

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