An Easy Way to Force Pre Approval & Pre Authorization: File a Workers’ Comp Prospective Utilization Review

Tired of waiting for pre-approval from the Pennsylvania (PA) workers’ compensation carrier to obtain needed treatment or medications? Tired of the lie that there is no such thing as pre-approval?

The simple, hardly ever used or know to exist, solution is to file a Prospective UR (Utilization Review) which is a quick and effective method of obtaining written pre approval of medical treatment bills that were otherwise not being paid by the workers’ compensation insurance carrier no matter what the reason or excuses provided by the workers’ compensation insurance carrier.

The injured worker’s request for Prospective Utilization Review is asking for a review of the injured worker’s medical treatment that they are going to need for the work related injury in the future. It is a request for the treatment to be pre-approved as reasonable and necessary going forward to prevent future denial and nonpayment of medical bills related to the work injury.

The advantages of the Prospective Utilization Review for the injured worker are several. The filing of the Prospective UR will generate a letter from the Pa. Bureau of Workers’ Compensation directed to the workers’ compensation carrier asking if the carrier wants to simply pay the bill and forgo the cost of the UR requested by the employee.

That is because the workers’ compensation carrier, not the injured worker, is responsible for paying the cost, regardless of who wins,  of the prospective UR even though the request is made by the injured worker. The cost for the carrier can range from several hundred dollars to well over a thousand dollars for the Prospective UR to be performed.

At that point, many times the carrier will simply agree, in writing, to pay the bills for the prospective treatment rather than incur the costs for the UR. If the carrier responds to this letter that they will not pre-approve the treatment, the matter will be assigned to a UR organization and a decision must be issued within 30 days of their receipt of the assignment from the Pa Bureau of Workers’ Compensation.

Therefore, in most instances the injured worker will quickly have a favorable decision within 30 days. Should the UR decision be unfavorable, the injured worker may file a petition to request a review the unfavorable UR decision within 30 days. Then, the higher burden of proof shifts to the employer and carrier to prove that the requested future treatment is neither reasonable nor necessary before a Workers’ Compensation Judge who will perform a fresh review to the need for the treatment.

If the Utilization Review (URO) finds the treatment to be reasonable, the carrier must pay for the treatment even if they file an appeal. In other words, while they waste time on an appeal, you are obtaining the treatment and the carrier must pay for it. There is never a situation where you would have to pay back the carrier for the treatment  if they win on appeal.

If you need help with a workers’ compensation issue, why not speak to an experienced Pennsylvania Workers’ Comp Lawyer for free. No matter where you live in the state, we can help. Call us at 1-877-291-9675.