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Ledgerwood Law Group

Struggling With Utilization Review After a Workers’ Comp Injury in California?

If you are waiting for an insurer to approve your medical treatment, you’re not alone. In fact, so many injured employees are waiting to hear back on their workers' compensation claims that a new law has been passed to expedite the system: Senate Bill 863.

Before the bill, it would typically take nine months to a year to resolve a dispute over medical treatment needed for an injury. Under SB 863, an independent medical review board will evaluate claims, bringing the decision wait time down to under 40 days.

The workers' comp utilization review (UR) process is not perfect. While all workers' compensation claims administrators are legally required to have a UR program, decisions are based on strict medical treatment guidelines that determine whether treatment is “medically necessary.” If your claim is denied, you have the right to appeal.

Denied? Here's What to Expect

  • After denial, you have 30 days to appeal the decision for an Independent Medical Review (IMR). This means that an independent doctor will make a final determination based solely on your medical records and documentation.
  • IMR can only be requested by an injured workers (or their attorneys or physicians) after denial, modification, or delay of a treatment request. Employers and insurance carriers cannot request reviews.
  • IMR is only able to resolve disputes over the medical necessity of a particular treatment requested by an injured worker’s physician. The review cannot make a ruling in cases where the injury itself is in question.
  • All IMR determinations are final. The only appeals allowed must be based on fraud, conflict of interest, or mistake of fact. Judges cannot overturn decisions based on the reviewer’s medical decision-making process. If an appeal is granted, the case will be referred to a different reviewer for another IMR.

 

If you are struggling with medical boards instead of getting the rest you need to heal, the Ledgerwood Law Group can take over your workers comp utilization review on your behalf. Contact us today at 888-761-7383 to find out how we can help, or click the link about to request a FREE copy of our report, The Northern California Workers’ Compensation Survival Manual.