By Christopher DiMeo, Esq.
Many have found themselves frustrated by the Utilization Review process. Have you experienced the rejected UR Requests for various reasons, never even getting to the URO for a Determination?
Recently I have experienced a new and concerning trend. Here is what occurred in one instance. A client filed a UR request on a provider’s treatment including durable medical equipment. After the assignment of the UR request to the URO, the provider requested a phone interview. In that interview, the provider advised the Reviewer he had not prescribed or provided durable medical equipment to the Claimant. The Reviewer took the word of the provider and refused to address the durable medical equipment in the Determination.
Here is the problem; the client had numerous medical bills and reports that prescribed durable medical equipment. Therefore, what were we to do? I filed a Review of the UR Determination. The strategy was to ask the WCJ to send the UR Determination back to the URO or request that the WCJ assign an impartial reviewer.
In this instance, the WCJ agreed with the argument that the URO needed to address the treatment in question based upon the fact that there were medical bills and reports for durable medical equipment from the provider under review. The WCJ issued an Order remanding the UR Determination back to the URO for a complete Determination.
Why the URO provider took the provider’s word despite medical bills that contradicted his statements, I cannot explain. However, this was not the only time I have encountered this result from a UR Determination. Therefore, since this does not appear to be an isolated incident, if faced with such a situation, I recommend a Petition to Review the Determination. Then seek a remand to the URO or an assignment by the WCJ to a peer review to address the medical treatment.