Utilization Review in Illinois: Missing an Opportunity

PRIUM’s General Counsel recently happened upon a post on a work comp law blog out of Illinois published by Eugene Keefe at Keefe, Campbell & Associates, LLP in Chicago.  The post was both fascinating and disappointing. 
Mr. Keefe’s extensive research on the application of new utilization review (UR) rules for the state work comp system shines a light on what happens when UR isn’t well understood (or perhaps what happens when UR is, in fact, well understood, but where the Work Comp Commission clearly leans in favor of claimants instead of the employer community.)  Despite the fact that the new rules were intended to give UR more weight and credibility in the process, it appears the Illinois Work Comp Commission (IWCC) is more interested in pleasing the plaintiffs’ bar.
During 2011, there were 32 UR decisions for which the dispute resolution process led all the way to a decision by IWCC.  In 23 of those 32 cases, the UR non-certification was overturned.  This doesn’t exactly inspire confidence amongst the employer/insurer community. 
Maybe there’s good reason those 23 decisions were overturned?  Not exactly.  In one case examined by Mr. Keefe, the reason for disregarding the UR determination was because “the utilization review doctor did not examine the Petitioner and his findings are based solely on record and diagnostic reviews.”  To this, Mr. Keefe responds appropriately, “Well, duh.”  The fundamental approach of UR is to examine records in search of documented, objective medical evidence that suggests a particular test, procedure, or therapy is medically appropriate.  And nowhere in the IL statute governing work comp is there even a suggestion that UR should require actual examination of the patient. 
So what’s an employer/insurer to do?  Do the right thing anyway.  Three reasons:
1)      A well structured UR non-certification may provide for a more informed Independent Medical Examination down the road;
2)      A UR non-certification may still have value in the settlement process, should the case progress to that point.
3)      Even if the odds don’t appear very attractive, engaging UR is still better than not engaging UR (and passively allowing inappropriate medical care to be rendered). 
In March of last year, the Chairman of Caterpillar (which employs 23,000 people in Illinois),  Doug Oberhelman, sent a letter to Illinois Governor Patrick Quinn which stated, in part, “The direction that this state is headed in is not favorable to business, and I'd like to work with you to change that.”   
Governor Quinn (and Governors everywhere) – are you listening? 

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