Comp head says utilization review outcomes ‘not binding’

Workers compensation payers using third party vendors to perform their utilization reviews for medical treatment for injured workers in Connecticut are responsible for “ensuring the timely and accurate processing” of comp claims and that decisions are not binding, according to a memorandum issued Monday by the state Workers’ Compensation Commission’s chairman.  

“It has been brought to my attention that utilization review is being used more and more frequently outside of medical care plans,” Chairman Stephen Morelli wrote in his memo urging payers to ensure compliance. “The entities performing these reviews are not holding to the timelines and standards established by the regulations, yet seem to be placing expectations on both claimants and providers that they need to follow the appeal timelines and regulations that they have set.”

“Should you choose to use a third party vendor for your utilization review needs, the onus is on you to ensure that the vendor is aware of the Workers’ Compensation guidelines surrounding utilization review,” the memo states.

Additionally, Mr. Morelli wrote that “while there is no explicit prohibition on utilization review, the outcome is not binding, and the Commission is not held to an ‘arbitrary and capricious’ standard to overturn a decision. It is, in these cases, the commissioner who makes the final determination as to the reasonableness and necessity of medical treatment.”