Utilization Review

Medicare & Work Comp Care Coordination

The following is educational information provided by the author and the Illinois Chiropractic Society. This information is not intended to replace legal counsel nor to provide legal advice. If a legal opinion is needed, please contact your attorney.

All of us look forward to opening mail from workers compensation carriers that contain checks, but no chiropractic physician wants to receive a letter indicating that their worker’s compensation bill is being reviewed. However, before you are faced with a review, chiropractic physicians in Illinois should be aware of the utilization review provisions that affect providers – especially since the NEW worker’s compensation reform became effective 09/01/2011.


The work comp insurance industry is facing numerous challenges, especially in the last few years. Health care costs in the work comp arena continue to inflate due to demographic, liability and other structural reasons. The only way insurers and employers can directly address some of these challenges are to control work comp costs by managing claims.

The insurers are beginning to implement the tools and technologies that help them deliver quality medical outcomes cost-effectively while decreasing medical bill processing costs. The best claims management solutions allow insurers to select providers most likely to produce the best medical outcomes and optimize bill review to ensure that appropriate billing practices and fee structures are implemented.

What are these tools?

Workers Compensation, in Illinois, continues to maintain “utilization review.”

As per Sec. 8.7. Utilization review program

Utilization review” means the evaluation of proposed or provided health care services to determine the appropriateness of both the level of health care services medically necessary and the quality of health care services provided to a patient, including evaluation of their efficiency, efficacy, and appropriateness of treatment, hospitalization, or office visits based on medically accepted standards. The evaluation must be accomplished by means of a system that identifies the utilization of health care services based on standards of care of nationally recognized peer review guidelines as well as nationally recognized treatment guidelines and evidence-based medicine based upon standards as provided in this Act. Utilization techniques may include prospective review, second opinions, concurrent review, discharge planning, peer review, independent medical examinations, and retrospective review (for purposes of this sentence, a retrospective review shall be applicable to services rendered on or after July 20, 2005). Nothing in this Section applies to prospective review of necessary first aid or emergency treatment.

Other provisions of utilization review law:

  • Requires providers to submit to reasonable written utilization review requests and to make reasonable efforts to submit timely and complete reports supporting a request for certification of requested treatment. If such reasonable efforts are not made, the charges may not be compensable or collectible.
  • Requires the written notices of certification and non-certification of requested treatment, including evidence-based guidelines, be furnished to the insurance provider and employee.
  • Provides that an employer or its agent can only deny requested medical treatment because the treatment is excessive or unnecessary based on a valid utilization review report.
  • Provides that if an employer or its agent refuses to pay for services based on a legitimate utilization review, the petitioner has the burden of establishing that variance with the guidelines are warranted in a particular situation.
  • Requires a physician performing utilization review to be available for deposition either in person or via phone conference.
  • Requires utilization review reports be addressed in any written decision.

As mentioned above, all providers will be and are affected by the utilization review. If you recall from a previous journal, I mentioned that with the NEW reformed Workers’ Compensation Act of 2011, the new Utilization Review is no longer a Chihuahua barking, but a Pit Bull with bigger teeth. However, utilizing the following 2 steps, doctors will put their treatment in a better position to be covered:

  1. You must document the delivery of the best outcome.
  2. You must document medical necessity!

Although documentation is a big concern of companies and workers compensation carriers, many carriers are not “anti-chiropractic.” In fact, during a recent meeting at the Work Comp Research Institute, I had a conversation with the CEO of a well-known work comp carrier. He stated that he has no problem paying chiropractic bills, as long as we show through our documentation the “best outcomes.”

Best outcomes? Yes, this is utilizing evidence-based treatment, showing medical necessity, documenting properly.

Dr. Boileve is a Certified Medical Compliance Specialist, as well as a candidate for Certified Insurance Consultant/Reviewer. He represents chiropractic on the medical advisory board of the Work Comp Research Institute for the State of Illinois.

About Author

Carlos Boileve, DC, MCS-P

After completing his schooling in Chicago, Dr. Boileve entered the National College of Chiropractic (NCC) now the National University of Health Sciences (NUHS) in 1976, graduating in 1980, and licensed in Illinois as a Chiropractic Physician.He is a Certified Medical Compliance Specialist, and on the Medical Advisory Board of the Workers' Compensation Research Institute (WCRI). Dr. Boileve is also is a Certified Insurance Consultant /Reviewer and has been on staff at the National College of Naprapathic Medicine since 2007 as an instructor in Histology, Anatomy, Embryology, Physiology, and Symptomology and Lab Interpretation.

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