What role does utilization review play in workers' compensation?

Utilization review plays a critical role in workers' compensation by focusing on the assessment of medical necessity for treatments provided to injured workers. This process involves evaluating whether the recommended or ongoing medical treatments are appropriate, necessary, and conform to established medical guidelines. By assessing the medical necessity, utilization review helps ensure that injured workers receive appropriate care while also managing the costs associated with their treatment.

When a treatment is proposed, the utilization review team examines relevant medical records, treatment plans, and any applicable clinical guidelines to determine if the proposed care is warranted. If the care is deemed necessary and appropriate, it is approved, allowing the injured worker to proceed with the treatment. Conversely, if the treatment is not considered necessary, the utilization review can dispute or deny the care, which ultimately helps to control excessive or unnecessary medical expenses in the workers' compensation system.

This process is vital not only for the well-being of the injured worker but also for the overall integrity of the workers' compensation program, ensuring that funds are utilized effectively and medical resources are allocated appropriately.