Many of you treat patients who have suffered an injury on the job. Often times, however, the employer tries to cut off payment of the injured claimant in a Workers Compensation setting by requesting a utilization review of the care being rendered. A recent opinion handed down by the Commonwealth Court entitled Stafford v. WCAB (Advanced Placement Services) dealt with the situation where the provider, in this case an osteopath, did not provide records when requested by the reviewing doctor in a utilization review setting. This case is instructive not only for its holding, but also because it provides a useful overview of how the utilization review system works.

In this case, the Utilization Review Organization (URO) determined that the care was not reasonable and necessary because the treating doctor provided no records.  The Court held that the Workers Compensation Judge did not have jurisdiction to determine on his own whether the care was reasonable or necessary. Even though the reviewing doctor had prepared a report, the Workers Compensation Judge had nothing to review because the reviewing doctor had nothing to review: i.e., the treating doctor had provided no records. The case, therefore, should not even have been assigned by the URO to the reviewing doctor.

The court reviewed some of the insurance regulations concerning utilization reviews in reaching its decision. The first regulation is that if a treating doctor fails to send in his documents within thirty (30) days of a request by the URO, the URO “shall render a decision that the treatment under review was not reasonable or necessary,” and the URO “…may not assign the request to a reviewer” (Pa. Code Section 127.464). The Court also went over what a reviewer must put in his report: “…a listing of the records reviewed; documentation of any attempted contacts with the provider under review; findings and conclusions; and a detailed explanation of the reasons for the conclusions reached by the reviewer, citing generally accepted treatment protocols and medical literature as appropriate.” (Pa. Code Section 127.472).

The bottom line is that when a request is made by a URO for your records it behooves you to supply them. This also applies when the reviewer calls your office to discuss the care rendered to the patient. My advice is to take the call and then argue as strenuously as you deem appropriate as to why your care is reasonable and necessary. Make sure you mention any consults that exist in the file. Don’t forget that you are the treating doctor and all the reviewer has is paperwork provided by the insurance company through the URO. You certainly know your patients better than someone who has never seen them.