Workers' Compensation Medical Cost Containment: Updated National Inventory

Purchase Table 17         Purchase Entire Study          View Table 18           Return to the List of Tables

Table 17  Utilization Requirements in Workers' Compensation Non-Managed Care Arrangements as of January 1, 2008

Utilization review refers to the review of the quantity and type of treatment provided to injured workers to ensure it is appropriate and medically necessary for the diagnosis.  This can be done in a number of ways and this table itemizes the most common utilization strategies and which ones states require in non-managed care settings.

State

Utilization Review Is Required

Who is Authorized to Perform Utilization Review Functions?

Which Claims Are Subject to Utilization Review?

State Agency Employees

State Agency Through Peer Review

Private Payors

Private Payors to Use Only Organizations Approved by State Agency

Only Certified Review Organizations

All Claims

All Claims but for Prospective Treatment Only

Claims Referred to the Agency

When Medical Costs Exceed Specific Amounts

When Disability Days Exceed  Specific Numbers

All Inpatient Hospitalizations

Planned Invasive Surgery

Documentation Necessary for Claim that Treatment Not Necessary

Sample State 1

No

x

Sample State 2

Yes

x

Those listed in the utilization review plan

WC agency opinion, independent fact finder opinion, agreement by the parties to the appropriate treatment

Notes: