Beware of “Utilization Review!” But, Don’t Let it Make You Give Up! By Tracy W. Cary

     Liberty Mutual and other insurance companies that provide workers’ compensation insurance coverage are taking a new approach in their attempt to make injured workers get frustrated and give up: it’s called “utilization review.” Don’t Fall For It!

    What they are saying is this: “We will pick the doctor we want to treat you. But if the doctor we pick to treat you wants to do something to treat you that we don’t want to pay for, we’ll get another doctor to overrule the doctor we told you to treat with.”

     Here’s how their scheme works: let’s say you are authorized to treat with Dr. Smith for your work-related injury. Dr. Smith thinks you need an MRI or physical therapy or an epidural injection or whatever it is. The Liberty Mutuals of the world (there are lots of them by various names) will hire a “utilization review” in which another doctor will be asked if Dr. Smith’s recommendation is “reasonably necessary.” Picture the “reviewing” doctor is out in Las Vegas in his pajamas. It’s probably not too far from the truth. The reviewing doctor will review some records, but many times not all the records. The reviewing doctor might try to call Dr. Smith but not necessarily. The reviewing doctor will never see you the injured worker. Then not surprisingly Dr. Pajamas will reach the conclusion that Dr. Smith’s recommendation is not reasonably necessary and the treatment will be denied by Liberty Mutual or one of the other usual suspects.

     A recent case I heard about involved the recommendation of a board-certified neurosurgeon overruled by a utilization review conducted by a dentist!

     So what do you do? Do you give up? That’s what Liberty Mutual and the others are hoping you’ll do. DON’T GIVE THEM THE SATISFACTION! The law is on your side! I handled a case that established the precedent for you. It’s called Ex parte Southeast Alabama Medical Center, and it can be viewed here: http://caselaw.findlaw.com/al-court-of-civil-appeals/1180416.html.

     The gist of it is this: You can ignore the utilization review. You aren’t bound by it! You can have a court order Liberty Mutual or whoever it is to provide you with the treatment that the workers’ compensation doctor says you need.

     As a lawyer who represents injured people for a living, I see this tactic over and over. It takes a little work and time, but I win these fights for my clients because the law is on your side in this regard.

Just remember: Don’t give up! If you need treatment, you can prevail.

Tracy W. Cary

Email: tcary@mcatlaw.com

Telephone: 1-800-638-3665