Utilization Reviews Can Limit Benefits Injured Illinois Workers Receive

Recovery from a workplace injury can take longer than expected. Employers and insurers are using a new review tactic to question whether long-term treatment is reasonable. In California, these utilization reviews are required in almost every workers' compensation case. While that is not yet the case in Illinois, utilization review can leave injured workers without access to needed treatment.

In one California case, a workers' compensation insurer stopped making payments after two years. This occurred even though the woman could not return to work and a medical examiner determined she was 70 percent disabled. In part, her problems stemmed from a state law that put in place utilization reviews. The change in law allowed insurers to deny claims more easily.

Before the change, insurance companies needed medical evidence to counter care recommendations. Following a utilization review, an insurance company could deny a claim and the only remedy for the worker was to appeal and see a certified medical examiner. The injured California worker whose payments were cut off eventually lost her home. She is still fighting and now calling for an investigation into insurer practices.

Illinois Reforms and Limitations on Utilization Reviews

Since the 2011 Illinois workers' compensation reforms, the number of utilization reviews in the state is increasing. An employer can deny payments for medical expenses if an accredited utilization review finds the treatment excessive.

A worker has the right to interview the medical professional who made the finding and the employer must pay the costs of the interview. In addition, the medical professional who completes the review must be located in Illinois. Employers were, however, unable to pass changes to the law that would have allowed the admission of these reports over hearsay objections and the introduction of causation comments.

The Illinois Department of Insurance oversees the program. Utilization techniques, to name a few, include:

  • Prospective reviews
  • Concurrent reviews
  • Second opinions
  • Independent medical examinations

Utilization review was initially justified to counter abuses in the workers' compensation system. The pendulum may be swinging too far to the other extreme, however, and some workers may not receive adequate treatment for workplace injuries.

Workers' compensation claims are complex and utilization reviews can affect your benefits. If an injury is not healing the way it should, or an employer is pushing for a return before you are ready, contact an experienced Illinois workers' compensation attorney. When injuries occur at the workplace, the Illinois workers' compensation scheme is meant to protect and provide for the full amount of time it takes you to recover.