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Christian Petrucci of the Law Offices of Christian Petrucci. Christian Petrucci of the Law Offices of Christian Petrucci.

As most workers’ compensation practitioners are aware, the utilization review process was one of the main aspects of the medical cost containment provisions of the 1993 amendments to the Workers’ Compensation Act. The system acts as a form of peer review, which subjects an injured worker’s medical treatment to evaluation by a licensed utilization review organization (URO), and specifically, an independent health care provider within the URO. The reviewing physician is to be of the same field and specialty as the provider under review and will author a report, commenting on the “reasonableness and necessity” of a the treatment in question. This utilization review (UR) determination is then subject to further review in a de novo proceeding by a workers’ compensation judge (WCJ) upon appeal by either party. The Act 44 utilization review process is the sole remedy for an employer to dispute the reasonableness and necessity of medical expenses as neither a WCJ nor the Workers’ Compensation Appeal Board have subject matter jurisdiction to determine the reasonableness and necessity of medical treatment.

Over the years, there have been many challenges to the UR process that the courts have had to decide. One such dispute even reached the U.S. Supreme Court at one point in American Manufacturers Mutual Insurance v. Sullivan, 526 U.S. 40 (1999), where Chief Justice William Rehnquist held that workers’ compensation insurers are not “state actors” under the Fourteenth Amendment to the U.S. Constitution and that the Pennsylvania UR process does not deprive injured workers property within the meaning of that amendment. More mundane challenges have included whether a UR determination is specific to the treatment under review or binding only on the provider under review. (It is the latter).

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