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Utilization Review Boards in Workers’ Compensation: Your Ticket to Nowhere


By: Kevin Kampschror, Esq.

If you were to see your own doctor under your own health insurance, would you give consent to another doctor, who has never seen you or met you, to look at your records and give a medical opinion about what you do and do not need? Would you then consent to that mystery doctor being able to modify your own doctor’s treatment plan, at times including things like physical therapy or even a surgery?

Under workers’ compensation (WC) laws in Nevada, you do not have a choice. Some insurers use “utilization review boards,” (UR) who will review the treating physician’s medical opinion and then give their own medical opinion and recommendations. Insurance companies can then simply disregard the treating physician’s recommendation and justify it with the utilization review board. If your treating physician has recommended knee surgery, and the UR has denied it, you have no option but to wait and appeal the decision (and wait on getting the surgery, so hopefully it is not anything you need fairly soon), or use your own insurance, and then hope that your appeal goes your way.

There are several enormous problems with UR. First, some doctor in another state is simply looking at a snapshot of your medical history, not meeting you, not talking to you, and not examining you, and then issuing an opinion. Second, what is the point of having only one treating physician under WC if insurance companies can simply pay companies like this to issue medical opinions, presumably ones in their favor? Third, what about your health – is money more important to insurance companies? Lastly, this is a possible HIPPA violation due to the insurance company sending your medical information, without your consent, to an outside party during your WC claim. This issue likely will need to be litigated.

Rest assured that UR is rarely used to modify the treating physician’s medical opinion and recommendation to adjust treatment to be increased or more expansive. It is almost always used to short change your physical therapy sessions from twelve (12) to six (6), deny a recommended surgery, deny post-operative treatment, deny things like TENS units, and deny much, much more.

This is a very complex area of WC law. As always, it is always advised you seek an experienced Las Vegas workers’ compensation attorney who is able to assist in obtaining all benefits that you are entitled to under Nevada law.

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