Changes To The Illinois Workers Compensation Act (Continued)
In my last post, we talked about those changes to the Act that affected an injured worker’s choice of doctor. Today we’ll focus on changes to the Act involving Utilization Reviews. Utilization Reviews (hereafter URs) are one of the tools that insurance company’s use to deny treatment that has been requested by a treating doctor. While this may sound cynical (I’m sure the insurance company would claim that URs are a tool for ensuring that treatment requested is reasonable and necessary), from the standpoint of an attorney who represents injured workers it is exactly what URs have become.
So, what is a Utilization Review, you might ask. The Illinois Worker’s Compensation Act defines a Utilization Review 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. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care of nationally recognized peer review guidelines as well as nationally recognized treatment guidelines and evidence-based medicine based upon standards as provided in this Act.” In short, this means that the insurance company has another doctor or peer of the requesting treater look over the treatment requested in light of the injury and provide an opinion as to whether or not the requested treatment is reasonable and necessary.
There are a number of the new changes that can affect your case. One is the requirement that the treating doctor “make all reasonable efforts to provide timely and complete reports of clinical information needed to support a request for treatment.” This does not simply mean that the doctor must provide his records when asked. Rather, it requires that the doctor answer questions that the insurance company’s Utilization Review may have regarding the patients condition or the suggested treatment. This added burden on the doctor comes with a metaphorical stick in that the doctor may not get paid if he is deemed “unccoperative.”
The second change that I want to talk about and the more important one has to do with the burden of proof at trial. If a UR exists, the injured employee now has the burden of proof to show that a variance from the standards used by the UR is “reasonably required to cure or relieve the affects of his or her injury.” Any shifting of the burden of proof on an issue is important in the legal arena. This change now puts the pressure and the burden squarely on the injured employee and his attorney. Why would the UR – done by a peer or doctor who likely never even examined the employee – be given more credence than the opnion of a treating doctor who is far more familiar with the employee and the injury being treated? That is a fine question, but not one that I can answer since I’m of the opinion that the treater is in the best position to provide opinions on these issues in most cases.
In any event, given these changes to the Illinois Worker’s Compensation Act, it is even more important that the injured worker make sure that he or she is represented by an attorney who knows the Act and handles these issues on a daily basis.