There was a recent presentation on the topic for the legal industry that was open to the public. We want to give you these highlights for your claims practice:
· An IL employer may only deny payment of or refuse to authorize treatment for medical services on an accepted claim when in compliance with UR done by an accredited UR review program.
· The UR program accreditation process is by the Illinois Department of Insurance.
· An IME alone will not be sufficient to analyze medical necessity, attack overtreatment and thereafter denial of care.
· UR shall be considered by the Commission and must be addressed along with all other evidence.
· It is still the impression of many in the utilization review business that UR in IL does NOT carry the same weight as it would in California or other states—we are all taking a wait-and-see approach but you have to first follow the rules.
· UR is not supposed to address causation—it is only supposed to address the appropriateness and medical necessity of treatment.
· Plaintiff attorneys, treating doctors and claimants all should and must receive UR findings.
· Numerous claimant attorneys have voiced their frustration in not receiving these reports—we urge all adjusters and UR providers not to “hide” their UR reports and determinations and turn the process into a cat-and-mouse game.
· We also feel the UR appeal process should be highlighted for claimant attorneys, treaters and claimants. If the defense industry makes claimants and counsel aware of the process and they use it as it was designed to be used, the UR process will be much more valid and compelling for the Arbitrators and Commissioners.
Please remember if you closely adhere to UR protocols and care is non-certified, the burden of proof shifts to the claimant side of the matrix to prove the care should have been certified. This is a major and beneficial change for employers in IL WC law, if the Arbitrators and Commissioners closely adhere to it.
One problem we continue to have is the concept of UR not being able to validly address causal connection. As a simple example, claimant was treated for two years for elbow pain without complaints or care other than to his arm. He then sought care for pain in his cervical spine and UR non-certified the care. Isn’t that a causal connection determination?