Workers’ Compensation law, although it can be straightforward at times, often has hidden intricacies that can trip-up even experienced practitioners. One such area is the use of “Utilization Reviews,” or “URs.” Although more common in other jurisdictions, they have seen limited use in Connecticut until recent years, and there are certain aspects of which every practitioner—both claimant and respondent—should be aware.
Generally, URs are a tool used by insurance carriers whereby they hire an outside contractor to do a file review of the claimant’s medical history and determine if any proposed treatment is reasonably necessary. In some jurisdictions throughout the country, respondents will often use these URs as a way to contest a claimant’s claim. In Connecticut, however, the method by which a respondent normally contests a claimant’s claim is the use of “Respondent’s Medical Exams,” or “RMEs”—not URs. URs do, however, have a limited purpose in Connecticut—namely, Conn. Reg. § 31-279-10 authorizes URs only when there is a “medical care plan” for the claimant to which the parties have agreed. Section 31-279-10(e) sets forth that in any medical care plan, there must be provisions pertaining to the use and execution of URs, and subsection (h) sets forth that the URs must have a method for resolving disputes and handling appeals of said URs. Under the circumstances where there is a medical care plan, therefore, URs are used, expected, and binding on the parties, including the URs appeal procedures.
The issue arises, however, with the continued use of URs outside of the medical care plan setting. Notably, on July 15, 2019, Chairman Morelli of the Workers’ Compensation Commission promulgated Memorandum 2019-06 addressing the use of URs outside of the medical care plan setting, and observed that such URs are not binding on any party. Although there is no prohibition on the use of URs, Chairman Morelli raised concerns that respondents were misleading claimants into believing that URs outside of a medical care plan setting were binding, and that the failure to follow the appeal procedures would invalidate the claimant’s claim—this is not true in Connecticut, and this misleading information had the potential, and perhaps tendency, to delay a claimant’s claim and potentially invalidate their claim due to time restrictions. Chairman Morelli, therefore, advised in this Memorandum that any respondent planning to use a UR outside of the medical care plan setting “MUST advise all parties, in particular medical providers, [that] the UR is not binding as there is no medical care plan in place.” (Emphasis in original.)
The message to claimants, therefore, is to take note if there is a medical care plan in place—or lack thereof—to determine whether they must comply with any appeal procedures and timelines therein. If there is no such medical care plan, claimants need not adhere to any decision in the UR, and should instead proceed with the normal procedures for validating their claim. The message to respondents, in turn, is that you should take care to use URs only in cases of medical care plans, and if you do use URs outside of said plans, advise all parties that the UR is not binding. Following this guidance ensures that all claims can be timely adjudicated and disposed without needless delay and confrontation.