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Workers’ compensation and the utilization review

On Behalf of | Jul 27, 2017 | Workers' Compensation |

Being injured on the job is no small thing. It may leave San Diegans with significant physical pain and suffering, but it can also leave one in a dire financial predicament. This can be especially true when one’s injuries render them unable to work. In conjunction with one another, medical expenses, rehabilitation costs and lost wages can all leave one feeling overwhelmed and unsure of how one is going to make ends meet. Of course, one may be able to receive workers’ compensation benefits, but there are certain limits on these benefits that, if not handled correctly, could leave one in a bad spot.

One common issue that comes up in workers’ compensation cases is what medical treatment an injured worker can receive. When one is injured on the job, they may think that they would recover best by receiving one form of treatment, but their employer and his or her insurer may think differently. This is where utilization review comes into play.

Utilization review is a mandatory process through which claims administrators and employers determine whether a proposed course of medical treatment is necessary for a worker’s injuries. To determine whether a course of treatment is necessary, medical professionals are required to make their recommendation based on evidence that a particular course of medical treatment can either cure or at least relieve the particular work injury in question. Therefore, a utilization review assesses whether a doctor’s recommendation fits this requirement.

If one disagrees with a decision made after a utilization review, they can file a complaint. They will need to be prepared to make arguments to support their position, though, which may be tricky, as utilization review is based on the law. For this reason, many Californians who are facing issues with their workers’ compensation claim or benefits choose to seek help from a qualified legal professional.



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