Fourth Quarter 2018
By: Heather MacKinnon
Question: Under what circumstances do you recommend a Utilization Review (UR) or an Independent Medical Examination (IME) in an otherwise compensable claim?
Short Answer: In Illinois, in an otherwise compensable claim, utilization reviews are primarily used to limit treatment, whether it be limiting excessive treatment or limiting unnecessary treatment or prescriptions. In-person independent medical examinations are useful for determining if a more invasive procedure is necessary, as well as, determining an AMA impairment rating, should the nature and extent of an injury be in dispute.
In a compensable claim, employers and insurance companies can request a utilization review to evaluate the medical necessity of proposed or previously provided medical treatment. Section 8.7 of the Illinois Workers’ Compensation Act governs the use of utilization review, which it defines as:
The evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. 820 ILCS 305/8.7(a)
If the utilization review finds that treatment is not medically necessary, the employer has legal basis to deny the treatment without being subjected to penalties for unreasonable conduct. If the utilization review denies treatment, the injured worker has the burden of proof to show by a preponderance of the evidence that the disputed treatment is reasonably required to cure or relieve the effects of his or her injury.
For example, in Centeno v. Illinois Workers’ Compensation Commission, 2016 IL App (2nd), the claimant suffered a back injury and visited his chiropractor 88 times. The employer sent the bills to utilization review which found that only 6 visits were medical necessary. Based on the UR denial, the Illinois Workers’ Compensation Commission found that the employer was not required to pay $30,461.68 in medical bills.
Not only can utilization reviews be used to limit the amount of treatment, but it also can be used to limit the type of treatments or prescriptions recommended. For example, if a treating physician recommended an epidural steroid injection for a minor injury, treatment records could be sent for a utilization review and a third party doctor would determine if that procedure was medically necessary. Typically, for more invasive procedures, an in-person independent medical examination would be recommended, as it would hold more weight should the case be tried. Additionally, utilization reviews do not address causation, where an independent medical examination would.
Independent Medical Exams
Independent medical examinations are governed by Section 12 of the Illinois Workers’ Compensation Act. In a compensable claim, employers may request an in-person independent medical examination to: determine if recommended treatment is necessary; what treatment should be prescribed, if any; if the employee has reached MMI; and what the AMA impairment rating is.
Similar to a utilization review, independent medical examinations can be used to limit treatment. Employers can request the independent medical examiner to comment on the necessity of a prescribed treatment and request if additional treatment is necessary.
Unlike a utilization review, an independent medical examination can determine what treatment the examiner would prescribe if they do not agree with the treating doctor’s recommendation. Additionally, unlike a utilization review, the independent medical examiner can determine if an employee has reached maximum medical improvement.
If an employee has reached maximum medical improvement, certain independent medical examiners have the ability to determine an AMA impairment rating. According to the AMA Guides, the physician’s role in performing an impairment evaluation is to provide an independent unbiased assessment of the individual’s medical condition, including its effects on function, and of limitation to the performance of activities of daily living, or “ADL’s.” This rating often times helps to lower a PPD value of the claim.
Employers can also have a records review performed by an independent medical examiner. Whether to utilize an in-person review, versus records review only, should be assessed on a case-by-case basis.
- Utilization reviews are designed to limit treatment. Often times injured workers are over-treated and it is important for employers and insurance companies to have utilization reviews performed when it appears treatment is becoming excessive and/or unnecessary.
- When an employer or insurance company is determining if a recommended surgery or invasive procedure is necessary, an in-person independent medical examination will hold more weight than utilization review. This is because an independent medical examiner will be able to conduct an in-person physical exam whereas a utilization reviewer would just review records.