Utilization review, also known as “UR,” is when a workers’ compensation insurance carrier challenges the necessity of medical care that has been ordered by the injured workers’ treating doctor.  To do this, they refer the case to an outside doctor, who then reviews the particular medical history, and then looks at the ordered treatment based upon what are termed the “Official Disability Guidelines,” sometimes used in conjunction with the AMA Guides to the Evaluation of Permanent Impairment.  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 patient’s treating doctor can then respond to the utilization review, and become a patient advocate, explaining why the treatment ordered is in fact medically necessary, which 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) 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 creators of the “Official Disability Guidelines” call themselves Work Loss Data Institute.  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” doctor says, and no matter what the “Official Disability Guidelines” claim.  Workers’ compensation insurance companies will always work extremely hard to save money by delaying and denying medical care.  Utilization review and the “Official Disability Guidelines” are just one example of how they cut costs, and a major reason why many injured workers choose to hire a qualified attorney who can take the insurance companies to court at the Illinois Workers’ Compensation Commission.

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