The Massachusetts Workers’ Compensation Act continues to be the primary source for the payment of medical expenses incurred to treat a work related injury or condition provided that the treatment is reasonable, necessary and related to the claimed injury.
In response to rapidly increasing medical costs, the legislature enacted provisions to the Massachusetts Workers’ Compensation Act that created a medical management component with which all injured workers and their medical providers must comply. Before one seeks non-emergency medical care for a work related injury, the plan for treatment must undergo Utilization Review by an agent designated by the workers’ compensation insurance company paying benefits. The insurer is required to provide a card to the injured worker, which identifies the UR agent, and includes a toll free number to contact it.
The role of UR is limited to a determination of whether the proposed treatment is reasonable and necessary. Utilization Review does not address issues of the cause of an injury, but rather focuses upon whether the proposed treatment is appropriate under the circumstances. In many cases, Utilization Review is guided by a protocol for the care of a particular injury.
Most medical care of an injury is subject to UR. However, there is no requirement that an injured worker undergo Utilization Review for an office visit. UR is designed to address treatment plans, which include such care as diagnostic testing (MRI, CT Scan), physical therapy and chiropractic treatment, and surgery.
Generally, a medical provider submits a proposed course of treatment to a UR agent which reviews the proposed treatment plan to consider whether it is reasonable and necessary. If the proposed treatment is found to be appropriate, written approval is issued to the worker and the provider. This does not guarantee payment, however, as the plan is then submitted to the insurance adjuster who determines if the treatment, though reasonable and necessary, is related to the claimed industrial accident and resulting injury. If it is, then the employee is free to seek the care; if it is not approved by the adjuster, then a claim at the Department of Industrial Accidents must be filed in order to obtain the suggested care.
If the UR agent denies the request for treatment, then either the injured worker or the medical provider must appeal the adverse determination by calling the UR agent or by sending them a written request for an appeal. Under the regulations, a call is sufficient. The UR agent must then conduct a peer-to-peer review between the provider who proposed the treatment plan and a person who practices in the same field of medicine. If the peer assessment results in another denial, then the injured worker must file a claim with the Department of Industrial Accidents in order to have the workers’ compensation insurer pay for the proposed care. If the peer reviewer agrees that the treatment is reasonable and necessary, then the claim moves to an adjuster who conducts an inquiry into the causal relationship issue. Once again, if the adjuster determines that the treatment is for an injury not related to the industrial accident, a claim must be filed in order to secure treatment.
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