When you’re hurt at work, and start your worker’s compensation claim, it’s just the beginning of a long and difficult process. You might think that things are very straightforward: you can’t work, therefore, you shouldn’t. But you might not have taken into account how insurance companies try to fight you.

They might deny the claim. They might say that you are faking. Or they might say that your injury shouldn’t actually prevent you from working. But, you think, you have an ace in the hole: you’ve got your treating physician’s statement saying that you shouldn’t be working. End of story, right?

Wrong. More often than not, the insurance company turns around and shows you something called the Utilization Review, based on the “Official Disability Guidelines.” It says that your injury isn’t really that bad, and that you can do the work. It’s even written by a doctor!

How does this third party know you? What gives them the right to judge your injury and medical services? And what makes the Official Disability Guidelines so, well, official?

It turns out that the guidelines are part of a large system that is built up to deny you your rights. It’s part of a system that makes it harder for the worker to defend themselves. And it is a reason why you need an experienced law firm fighting in your corner.

Your Utilization Review

After you’ve been injured and proved, with a doctor, that you are hurt, your employer or their workers compensation insurance company will have what is called a Utilization Review, to see if, well, you can be utilized. If the UR says that your injury isn’t bad, you can stop getting the benefits you deserve.

The word “utilization” here is key. They want to know if you can be utilized: in other words, if you can work. Does it sound dehumanizing? It is. And that’s the point. To the insurance company, you’re just a number on a spreadsheet, and your best interests hurt their bottom line.

How the “Official Disability Guidelines (ODG)” Get Written

Do you remember the Great Recession of 2008? Among other things, one of the problems is that the agencies who were grading the stability and strength of the big banks and other institutions were being paid by the banks. They had financial incentive to say exactly what the banks wanted to hear. Even if it wasn’t directly corrupt, there was subliminal pressure to tailor the message.

That’s sort of like what happens with the Official Disability Guidelines. The “Official Disability Guidelines” are created by an organization which has a financial interest in making the guidelines as conservative as possible. As long as the “guidelines” are conservative enough, then the creators of the ODG are assured to keep their clients, which include employers, TPA’s, and insurers.

In an overwhelming majority of cases, this “utilization review” using the “Official Disability Guidelines” results in a conclusion that includes the following words: “Therefore, the request is not medically necessary within Official Disability Guidelines that recommend…” Then, of course, the injured workers’ medical care is stopped, delayed, and/or denied.

The creators of the “Official Disability Guidelines” call themselves Work Loss Data Institute. That’s quite a name. The thing that they are most concerned about is “Work Loss”, and not, say “worker health”. Work loss is also defined very narrowly: any injuries, no matter how severe, are work loss.

On their website, one can find their mission statement, which includes: “Apply evidence-based medicine to improve healthcare outcomes.” On another page, they boast that, “The outcomes speak for themselves. Adoption of ODG has led to: Medical cost-savings of 25%-60% (by state, payer, TPA, and health plan).”

Another revealing clue is the following line: “Focus on working people (RTW = getting better).” This statement is certainly not logical. In workers’ compensation terms, “RTW” stands for “return to work.” So, here we have the creators of the ODG stating that, to a degree, returning an injured worker back to work is “equal” to that person “getting better.” In many cases and with many particular injuries, this idea could not be further from the truth.

If a worker has a severely torn rotator cuff, for example, and his job requires heavy lifting and constant use of the injured shoulder, then the only way he can “get better” is to undergo surgery (by a qualified surgeon) as soon as possible, rest the shoulder, and then progressively strengthen it in physical therapy over the course of several weeks. Therefore, rushing to return that same worker to work before he undergoes necessary medical care would be the absolute worst thing to do, no matter what a “utilization review” reviewing physician says, and no matter what the “Official Disability Guidelines” claim.

“Improving healthcare outcomes” doesn’t mean improving your health. It means rushing you back to work without paying for needed surgeries or rest. It’s how they fight you.

Fight Utilization Reviews With Experienced Attorneys

Chances are you wouldn’t have heard of a utilization review before you are injured, and might think that it is just as official as your doctor’s report. Too many people give up. But you can still fight it.

The patient’s treating doctor can then respond to the utilization review, and become a patient advocate, explaining why the reviewed medical treatment ordered is in fact medically necessary. The medical treatment requested is often supported to a greater degree when the particular treating doctor has a strong educational foundation and reputation in a related field of medicine.

Even in such a situation, the injured worker usually needs a lawyer to fight for his or her rights, and to take the workers’ compensation insurance company to court (at the Illinois Workers’ Compensation Commission). It’s important to lay out the argument that the treating doctor’s ordered treatment is medically necessary, despite the fact that a “utilization review” doctor claimed that the “Official Disability Guidelines” do not support such ordered treatment.

The thing is, insurance companies have a whole army of lawyers and professionals dedicated to not paying you. It’s their job. And not only that, but they have this whole auxiliary industry that gives them support, no matter how spurious. That’s why you need someone who has taken on the insurance companies, and knows all their tricks, and knows how to fight them. It’s important to know when to hire an attorney, so that you can get your case made.

Your injury started the process. The Official Disability Guidelines don’t get the final word. We’ll make sure you do.

AMA Guides, Illinois Workers’ Compensation Commission, Medical Care, ODG (Official Disability Guidelines), Utilization Review

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