Thank you for sharing!

Your article was successfully shared with the contacts you provided.
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).

This content has been archived. It is available through our partners, LexisNexis® and Bloomberg Law.

To view this content, please continue to their sites.

Not a Lexis Advance® Subscriber?
Subscribe Now

Not a Bloomberg Law Subscriber?
Subscribe Now

Why am I seeing this?

LexisNexis® and Bloomberg Law are third party online distributors of the broad collection of current and archived versions of ALM's legal news publications. LexisNexis® and Bloomberg Law customers are able to access and use ALM's content, including content from the National Law Journal, The American Lawyer, Legaltech News, The New York Law Journal, and Corporate Counsel, as well as other sources of legal information.

For questions call 1-877-256-2472 or contact us at [email protected]

Wrongful Use of Civil Proceedings Related Torts in PennsylvaniaBook

A comprehensive review of the body of law upon which wrongful use litigation is built, based and written upon years of experience and a close study of the jurisprudence.

Get More Information

America's Claims Executive Virtual Leadership Forum & Expo 2021Event

ACE Virtual Leadership Forum & Expo is the annual conference for Senior Claims Executives in Insurance organizations.

Get More Information

ALM Legal Publication Newsletters

Sign Up Today and Never Miss Another Story.

As part of your digital membership, you can sign up for an unlimited number of a wide range of complimentary newsletters. Visit your My Account page to make your selections. Get the timely legal news and critical analysis you cannot afford to miss. Tailored just for you. In your inbox. Every day.

Copyright © 2021 ALM Media Properties, LLC. All Rights Reserved.