A Publication of WTVP

What do plaintiff attorneys and many workers’ compensation (WC) insurance carriers have in common? Both evidently believe that everyone injured on the job wants or needs to litigate.

Attorneys believe this for obvious reasons—it’s their livelihood. But, do many insurance carriers believe the same thing? One might conclude so. One carrier recently stated that it “takes its time” preauthorizing necessary medical diagnostics, such as MRIs, under the “utilization review” law for fear of “opening a can of worms” (i.e., identifying pre-existing conditions). It’s ironic that the one not representing the employer wants care to be delayed or denied because it brings business through the law office doors—a local commercial says as much—while the one representing the employer is afraid of opening the mythical container of fish bait, and in turn, delays and denies reasonable and necessary care. Meanwhile, the injured employee dials 1-800-LITIGATE.

Utilization review, or UR, is a quality control process, which under Illinois law, must use objective, evidence-based medical standards to determine if treatment was reasonable for an injury. If care was excessive or unnecessary, an insurance carrier or employer—on the advice of another qualified medical provider—can deny payment for that care. Insurance carriers or employers can also request providers to submit medical records for review to determine if a proposed medical procedure is necessary.

UR is powerful when used properly. California’s WC carriers and employers, whose system is touted by many in the Springfield legislature as Illinois’ model, uses UR in the same way Illinois is now seeing it implemented. However, though a potential cost-reducer, a recent review concluded that UR misuse is a great concern. I will note that this review was conducted by the California Labor Federation (CLF)— probably not an “employer-friendly” group as I would define it. However, I caution to not dismiss it as simply propaganda, as those who subscribe to such organizations also routinely initiate WC litigation.

“Sending cases to utilization review has, in some cases, become one way for insurance companies to delay and deny needed medical treatment,” reports the CLF. “Out-of-state doctors, paid for by the insurance companies, work out of their specialty area and review the decisions of California doctors. UR has simply become a new tool with which insurers hang onto their premium dollars a little longer.”

But, that’s California…does it happen here? Until recently, IWIRC had never lost a UR. Its first came recently when an IWRC physician evaluated a knee injury that was denied an MRI by an out-of-state physician’s UR conclusion. IWIRC’s physician determined the MRI need using the established medical criteria of the insurance carrier itself— an extremely large carrier. The UR physician’s specialty: hormone replacement therapy. His reasons for the UR denial: 1) Not enough narcotics used during treatment, and 2) Not asking for the patient’s pain level on a scale of 1 to 10 before ordering the MRI. Neither are established criteria for denial, nor good medicine.

If nothing else, this offers insight into a plaintiff attorney’s or injured employee’s motive for litigation. While the WC carrier desires to save money, its misuses of UR have but one likely outcome—one more catalyst to introduce Illinois injured workers to that lawyer in the commercial. iBi