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Rule 16: Review vs Utilization Review

The Colorado Workers’ Compensation Act places a responsibility on insurers and employers to provide medical treatment to employees affected by work injuries. However, the question arises: are insurers and employers liable for all treatments recommended by authorized treating providers (ATPs)? The answer, as explored in this article, is nuanced. While they must cover reasonable, necessary, and work-related treatments, the process involves various considerations and potential pitfalls.

Understanding Utilization Review:

Treatment requests typically undergo an internal Utilization Review (UR) process conducted by insurers or third-party administrators (TPAs). During UR, healthcare professionals evaluate whether a proposed treatment is medically necessary. However, UR does not assess the relatedness of the treatment to the work injury, a crucial factor in cases involving prior injuries to the same body part.

Illustrative Scenario:

Consider a scenario where an employee had a successful right knee surgery in 2015. In 2018, an ATP recommended a total knee replacement following a work-related injury to the same knee. The insurer then has two strategic options for addressing the request, each with its implications.

Strategy #1: The UR Dilemma

In the first strategy, the insurer opts for a routine UR process. The request goes to an occupational medicine physician who does not necessarily specialize in orthopedics. It is not accredited as Level I or II with the Colorado Division of Workers’ Compensation. This approach may lead to unforeseen challenges:

Scenario A: If the UR report deems surgery medically necessary without addressing relatedness, the insurer may find itself obligated to authorize surgery, as relatedness cannot be denied without proper medical support.

Scenario B: If the UR report concludes surgery is not medically necessary, the denial might be challenged. Suppose opposing counsel identifies shortcomings in the reviewing physician’s qualifications. In that case, they may file an Application for Hearing, potentially resulting in default authorization.

Strategy #2: Proactive Expert Involvement

In the second strategy, the insurer takes a proactive approach by quickly engaging a Level I- or II-accredited orthopedist to review the case within the 7-business-day deadline. This expert evaluates the medical records, including pre-injury records from the prior surgery, and provides a comprehensive report addressing relatedness. The insurer then uses this expert opinion to formulate a Rule 16 denial letter, ensuring compliance with the statutory requirements.

The Lesson Learned

The key lesson from this scenario is clear: when concerns arise regarding the relatedness of treatment to the work injury, opting for a Rule 16 records review or an Independent Medical Examination (IME) instead of relying solely on UR may be prudent. While this approach may entail additional costs, it can offer more excellent protection from potential litigation. Furthermore, seeking legal assistance promptly ensures that the denial process adheres to Rule 16 requirements, safeguarding the validity of the denial letter.

In navigating the intricate landscape of Rule 16 and its implications on the review and utilization review processes, it becomes evident that a nuanced understanding is essential for legal practitioners and stakeholders alike. The intricate balance between review and utilization review, as outlined in Rule 16, underscores the significance of a judicious approach to information evaluation and application. Thomas & Ahnell, LLC, with its commitment to legal excellence and expertise, emerges as a pivotal player in deciphering and navigating these complex legal terrains. As professionals grapple with the intricacies of Rule 16, the firm’s dedication to providing comprehensive legal solutions positions it as a reliable guide in the realm of review and utilization review, offering invaluable insights that transcend the boundaries of mere compliance.

Do you have further questions or concerns? Call us or contact the attorneys at Thomas & Ahnell, LLC, and we will be happy to help.

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