Under the Pennsylvania (PA) Workers’ Compensation Act, A UR, or Utilization Review, is a process by which an insurance company can have a workers’ compensation related treatment reviewed to determine if the treatment is both “reasonable” and “necessary”. When a treatment is reviewed, the Bureau assigns the review to a Utilization Review Organization, or URO. It takes about 5 days for the bureau to assign the petition for utilization review to a reviewing organization. The URO then attempts to collect all medical records related to the course of treatment, apply generally accepted protocols as appropriate to the individual case, and then determine if the treatment is in fact “reasonable” and “necessary”. For purposes of the UR, it is assumed that the treatment is causally related to the workers’ compensation injury. In addition to causation, the URO can also not comment on disability status.
A request for a UR shall be deemed complete upon receipt of the medical records from the provider, or 35 days after the notice of assignment of the review, whichever comes first. Failure of the treating doctor to timely provide records will cause the treatment to be denied as not reasonable and necessary. Once a request is completed, the URO shall have 30 days to render its decision. If a provider fails to render all of its medical records within 30 days of the URO’s request, the treatment in question will automatically be deemed “unreasonable” and “unnecessary”. Therefore, it is imperative that a provider renders all relevant records within 30 days of the request.
If a provider, an employee, or an employer disagrees with the UR determination, any party can file a request for review of the UR determination. This request must be filed with the Bureau of Workers’ Compensation within 30 days of receipt of the UR determination. The petition for review will then be assigned by the Bureau, and the original UR determination will be used as evidence but will not be binding upon the Workers’ Compensation Judge.
We represent many injured workers and treating doctors in getting their bills paid on appeal from a negative UR determination. When hired by the physician or medical provider, our fee is 20% of the past due bills we obtain payment for on appeal.
Under the Pennsylvania Workers’ Compensation Act, the Utilization review organization is to reimburse the doctor or medical provider, within 30 days, the actual postage charges and the copying charges at the rate specified by Medicare. Films shall be reimbursed at the usual and customary charge. See Section 127.463 of the PA Workers’ Comp Act. For a free copy of our book The Almost Hassle Free Way to Collect Workers’ Comp Medical Bills, contact Calhoon and Kaminsky P.C.