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Does utilization review really increase litigation rates?

Utilization review (UR) is an effective and proven approach that ensures injured workers receive timely and appropriate medical treatment for their work-related injuries. With UR, nurses review medical requests, comparing them to evidence-based guidelines to avoid unnecessary treatments and surgeries.

Despite the benefits that utilization reviews provide, there is still a misunderstanding that these reviews lead to higher litigation rates. It’s not difficult to see why this misconception exists. Many attorneys who represent injured workers have seized upon utilization review as a “barrier to treatment.” In fact, some attorney websites describe utilization review as a step that is “frivolous and wasteful,” and “slows down” access to medical care. Aggressive marketing tactics by attorneys often reinforce this belief that increased litigation rates largely outweigh the benefits.

Sedgwick analyzed more than 100,000 claims over a three-year period to determine whether utilization reviews really increased litigation rates. We found that, while they impact the delivery of medical care on workers’ compensation claims, it is not in the way you may expect. Sedgwick’s analysis concluded the following:

  • Only 2.6% of claims moved to litigation within 30 days of the first UR date
  • Only 1.2% of claims moved to litigation within 30 days of the first UR denial date

These results dispute the widespread belief that the use of utilization review drives an injured worker to seek an attorney.

Further analysis uncovered an even more interesting relationship between utilization reviews and litigation. While many attorneys advertise their willingness to help injured workers get the medical care they deserve, what they are often doing is making the injured worker undergo unnecessary treatment, much of which is outside of evidence-based medicine. In fact, once an attorney was engaged, our data showed the following:

  • 64% increase in the frequency of utilization reviews for medical care
  • 14% increase in the number of requests that fall outside of evidence-based guidelines and could lead to further complications down the road

These conclusions speak to how important it is for injured workers, treatment providers and employers to understand the role of utilization review. UR protects injured workers from unnecessary medical care and helps them avoid potentially invasive treatments. Rather than being a barrier, UR serves as an important tool that helps facilitate a safe recovery, with little bearing on whether or not a claim is eventually litigated.

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