Can my employer challenge the reasonableness or necessity of my medical treatment?

Yes. An employer has the right to challenge the reasonableness and the necessity of medical treatment by filing a Utilization Review Petition with the Bureau of Workers' Compensation. Bills submitted within 30 days of filing the petition may be reviewed. The Petition will be assigned to a Utilization Review Organization that will request your medical provider to send a copy of your medical records and will request a statement from you regarding your perspective on the treatment you received.

The Utilization Review Organization will assign your case to a doctor who practices in the same medical specialty as your treating doctor, and that doctor will issue a report that states whether your treatment was reasonable or necessary.

If your physician or medical provider fails to provide copies of your medical records to the Utilization Review Organization, the treatment will ordinarily be found to be unreasonable or unnecessary. It is therefore essential that your provider forward copies of your medical records to the Utilization Review Organization if your treatment is being reviewed.

If the Utilization Review Organization finds that your treatment was wholly or partly unnecessary or unreasonable, you as well as your doctor have the right to appeal this decision to a workers' compensation judge. You are not required to pay for any treatment that the Utilization Review Organization deemed unnecessary or unreasonable. The Utilization Review process is also discussed extensively in my free booklet, The Doctor's Guide to Pennsylvania Workers' Compensation Billing.