What Is Utilization Review in Workers' Compensation?

If you or a loved one suffered a work-related injury or illness in Nebraska, you may encounter the term “utilization review” as your case goes through the workers’ compensation system. Utilization review is a process that insurers use to evaluate the medical necessity of treatment for your condition. Understanding how utilization review works can help you secure the care you need to recover and return to work.

At Mueller Schmidt Mulholland & Cooling, our experienced workers’ compensation attorneys help injured workers in Omaha and throughout Nebraska obtain the full medical and wage loss benefits they deserve. Call 402-999-9000 for a free consultation with one of our lawyers to learn how a utilization review can affect your claim and your benefits.

What Is Utilization Review?

A utilization review involves a medical professional (usually a nurse or doctor) not involved in your direct care reviewing your proposed treatment plan and medical records. They assess whether the care in question (sometimes a particular procedure, sometimes a course of treatment) is medically necessary, appropriate, and aligned with accepted standards. The reviewer considers factors such as your diagnosis, the expected treatment outcomes, medical guidelines, and the cost and duration of the proposed care. Based on this review, the utilization reviewer either approves the treatment, makes modification recommendations, or denies it as not medically necessary.

The Utilization Review Process in Nebraska

In Nebraska, workers’ comp insurers must have a utilization review program to evaluate the medical necessity of proposed treatments. The process typically follows these steps:

• Your treating doctor submits a request to authorize a specific treatment plan.
• The insurer’s utilization review department assigns the request to a licensed Nebraska reviewer specializing in the relevant medicine area.
• The reviewer evaluates your medical records and the proposed treatment plan to determine if it meets medical necessity criteria. They may contact your doctor for additional information.
• The reviewer decides to approve, modify, or deny the treatment and communicates this decision to the insurer, you, and your doctor.
• If the treatment is denied or modified, you can appeal within 15 days. The insurer must assign the appeal to a different reviewer.
• If the treatment is still denied after the appeal, you may need to consider alternative options or file a dispute with the Nebraska Workers’ Compensation Court.

Common Reasons for Treatment Denials

Insurers may deny a requested treatment during utilization review for reasons such as:

• The treatment is not related to your work injury.
• The treatment is not medically necessary or in line with accepted standards.
• The treatment is not the most cost-effective option.
• The treatment is not expected to improve your condition.
• The treatment is not authorized under Nebraska’s workers’ comp rules.

A denial does not necessarily mean you are not entitled to any medical care for your work injury, but it can delay necessary treatment and add stress to an already challenging situation.

Your Rights in the Utilization Review Process

As an injured worker in Nebraska, you have the right to:

• Receive necessary medical care related to your work injury.
• Appeal utilization review denials.
• Have legal representation to help you navigate the system.
• File a dispute with the Workers’ Compensation Court if you disagree with a final utilization review decision.

How Mueller Schmidt Mulholland & Cooling Can Help

Navigating the workers’ comp system and waiting for the results of a utilization review can be overwhelming, especially when you are already coping with a work injury. Our knowledgeable attorneys at Mueller Schmidt Mulholland & Cooling are here to help. We can:

• Provide a free consultation to discuss your case and rights
• Gather medical evidence to support your need for treatment
• Communicate with the insurer about getting your treatment approved
• Represent you in appeals and disputes if your treatment is denied
• Offer compassionate guidance and support throughout the process

If you face obstacles to getting the medical care you need after a work injury, do not hesitate to contact our team for assistance. We work on a contingency fee basis, so you owe no attorney fees unless we recover benefits for you.

Contact an Omaha Workers’ Compensation Lawyer Today

At Mueller Schmidt Mulholland & Cooling, we dedicate ourselves to helping injured workers in Nebraska get the care and benefits they deserve. Our mission is centered around supporting injured workers throughout Nebraska, ensuring they receive the care and benefits they rightfully deserve. We understand the complexities and challenges that can arise when navigating work-related injuries, and we’re here to guide you every step of the way.

If you are dealing with a utilization review issue or other challenges related to your work injury, contact us today at 402-999-9000 for a free consultation. Let us put our experience and commitment to work for you and your family.